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Deborah Quilgars and Nicholas Pleace
2017
Report of the University of York Evaluation
The Threshold Housing First Pilot for
Women with an Offending History:
The First Two Years
Copyright © University of York, 2018
All rights reserved. Reproduction of this report by photocopying or electronic means for non-
commercial purposes is permitted. Otherwise, no part of this report may be reproduced,
adapted, stored in a retrieval system or transmitted by any means, electronic, mechanical,
photocopying, or otherwise without prior written permission of the Centre for Housing
Policy, University of York.
ISBN: 978-0-9929500-7-1
Further copies of this report or any other Centre for Housing Policy publication can be freely
obtained by visiting our website: https://www.york.ac.uk/chp/
Acknowledgements ................................................................................................................................ i
Disclaimer .............................................................................................................................................. ii
Executive Summary ............................................................................................................................... iii
Referrals to the service ........................................................................................................................... iii
Profile of the women using the service .................................................................................................. iii
Delivering the Threshold Housing First service ...................................................................................... iv
Service outcomes ..................................................................................................................................... v
Housing outcomes ......................................................................................................................... v
Impact on health and well-being .................................................................................................. vi
Offending behaviour ..................................................................................................................... vi
Conclusion ............................................................................................................................................... vi
1. Threshold Housing First ................................................................................................................. 1
Introduction ............................................................................................................................................. 1
The Housing First Concept ....................................................................................................................... 1
Threshold Housing First ........................................................................................................................... 4
Homeless women with complex needs ......................................................................................... 4
Homelessness and offending ......................................................................................................... 4
The development of Threshold Housing First ............................................................................... 5
2. The Women Using Threshold Housing First .................................................................................... 7
Introduction ............................................................................................................................................. 7
Referrals ................................................................................................................................................... 7
Perspectives on referral and assessment procedures ................................................................... 7
The Women using Threshold Housing First ............................................................................................. 8
Characteristics ............................................................................................................................... 8
Housing situation at referral and experience of homelessness .................................................... 8
Support needs at referral ............................................................................................................ 10
Contact with the criminal justice system .................................................................................... 12
Summary ................................................................................................................................................ 13
3. Using and Delivering Threshold Housing First ............................................................................... 14
Introduction ........................................................................................................................................... 14
Use of the Threshold Housing First ........................................................................................................ 14
Duration of support ..................................................................................................................... 14
The support provided .................................................................................................................. 15
Staff and Agency Views on Service Delivery .......................................................................................... 16
Joint working ............................................................................................................................... 17
Using the Threshold Housing First Project: The Views of Women ........................................................ 18
A comprehensive service ............................................................................................................. 18
Frequent/available service .......................................................................................................... 18
A reliable service.......................................................................................................................... 19
Contents
A ‘positive’ advocate approach ................................................................................................... 20
Choice and control ....................................................................................................................... 20
Fidelity with the Housing First Model .................................................................................................... 21
Summary ................................................................................................................................................ 23
4. Outcomes ................................................................................................................................... 24
Introduction ........................................................................................................................................... 24
Housing Outcomes ................................................................................................................................. 24
Housing sustainment ................................................................................................................... 24
Other housing outcomes ............................................................................................................. 25
Housing quality ............................................................................................................................ 25
Securing housing.......................................................................................................................... 26
Impact and meaning of successful rehousing ............................................................................. 27
Health and Well-being ........................................................................................................................... 28
Mental health .............................................................................................................................. 28
Addiction...................................................................................................................................... 29
Physical health ............................................................................................................................. 29
Social Integration ................................................................................................................................... 30
Education, training and employment .......................................................................................... 30
Crime and anti-social behaviour .................................................................................................. 30
Social Networks ..................................................................................................................................... 32
Relationships with (ex-)partners ................................................................................................. 32
Relationships with children ......................................................................................................... 32
Relationships with wider family and friends ............................................................................... 33
Relationships with neighbours/ neighbourhood ......................................................................... 33
Summary ................................................................................................................................................ 34
5. Estimates of Cost Effectiveness.................................................................................................... 35
Introduction ........................................................................................................................................... 35
Contrasting Threshold Housing First and ‘Treatment as Usual’ ............................................................ 35
Estimating the Cost Effectiveness of Threshold Housing First............................................................... 36
A high cost, high saving scenario ................................................................................................. 36
A medium cost scenario .............................................................................................................. 38
A Scenario where Threshold Housing First may increase short-term costs ................................ 39
Potential Savings in Local Authority Spending....................................................................................... 40
Measuring Costs .................................................................................................................................... 40
Impact of Project on Agencies ............................................................................................................... 41
Summary ................................................................................................................................................ 41
6. The Future for Threshold Housing First ........................................................................................ 42
Introduction ........................................................................................................................................... 42
The Achievements of Threshold Housing First ...................................................................................... 42
The Case for Dedicated Housing First Services for Women .................................................................. 42
A Strategic Role for Threshold Housing First in the Greater Manchester Combined Authority ........... 44
Summary ................................................................................................................................................ 46
i | P a g e
We would like to thank all the women using Threshold Housing First for choosing to share their views and
experiences with us, as without their support this research would not have been possible. Our thanks also go
to the teams running and managing Threshold Housing First and everyone involved in the service who has
helped us with the research. We are also grateful to those working in agencies working in partnership with
Threshold who gave up their time to be interviewed for the research.
Deborah Quilgars and Nicholas Pleace
Centre for Housing Policy
University of York
York
September 2017
Acknowledgements
ii | P a g e
The views presented in the report are not necessarily those of Threshold or the University of York.
Responsibility for any errors rests with the authors.
Disclaimer
iii | P a g e
Threshold Housing First represents the first
significant attempt to develop a specialist form of
Housing First, targeted on homeless women who
had a history of offending. Set up as a pilot service
for two years in 2015, the Threshold Housing First
was designed to support up to 12 women with high
and complex needs, with experience of
homelessness, at any one point. The service has now
received a further three years funding and is being
delivered in three local authority areas in Greater
Manchester: Tameside, Stockport and Oldham.
Threshold commissioned the Centre for Housing
Policy, University of York, to conduct an independent
evaluation of Threshold Housing First’s first two
years. Qualitative interviews were undertaken with
women using Threshold Housing First, with the
workers and managers providing the service, and
also partner agencies working with Threshold.
Researchers also analysed data collected by the
project to examine referral patterns, support needs
and service outcomes.
Referrals to the service
A total of 33 women used the Threshold Housing
First between April 2015 and April 2017 (14 of these
cases still open at the end of the pilot period).
Criminal justice related services were the main
referrers to the service (67%); other referral sources
included homelessness services and other Threshold
services.
Overall, referral and assessment arrangements
operated well. Staff reported a strong demand for
the service in all areas, and clearly could have filled
additional spaces on the service had these been
available. Some service users were nervous about
meeting new workers but, when introduced,
commented that they were approachable from the
outset.
Profile of the women using the
service
The youngest woman to use Threshold Housing First
was 18 at referral, the oldest was 52 (with an
average age of 32). Almost all the women using the
service (97%) were of White European origin, all
were British citizens and all had English as their first
language.
The majority of the women (79%) were parents, but
none had their children living with them at the point
of referral. Sometimes children were old enough to
be living independently, but interviews showed that
the offending profile of many of the women had
been associated with children being taken into care.
The women were almost all single at the point of
referral (82%).
The majority (19 women, 58%) of the 33 women
who used Threshold Housing First pilot service were
recorded as homeless at point of referral. This
included living rough, living in tents, refuges,
hospital, supported housing, Bail hostel and nine
women who were ‘hidden homeless’. In addition, 11
women (33%) were about to leave prison with no
home to go to. A small group of women were at risk
of homelessness (3 women, 9%).
Women using the Threshold Housing First had
experienced many adverse circumstances in their
lives. Experience of domestic violence was near-
universal (94%), with experience of mental health
problems also being self-reported as very
widespread (91%), as well as physical health
problems (91%). Drug and alcohol problems were
also reported by almost all the women using
Threshold Housing First. Experience of prison was
also high (16 of the 33 women). Several women had
experience of the care system as children and seven
reported an experience of staying on a psychiatric
ward or unit (Figure 1).
Executive Summary
iv | P a g e
Figure 1: Self-reported experiences of the women
using Threshold Housing First
Source: Anonymised data collected by Threshold.
Note: data were not collected for one woman using the service.
The women who had been supported by Threshold
Housing First had all had contact with the criminal
justice system. Eight women (24%) had one
conviction each, but for another group contact had
been repeated (13 women reported more than 10
convictions each, 39%). Fourteen women had
support in place from Probation services.
Delivering the Threshold
Housing First service
The Threshold Housing First service has high ‘fidelity’
to the core principles of Housing First as outlined in
the Housing First Guide Europe1, developed by
FEANTSA:
Housing is a human right
Choice and control for service users
Separation of housing and treatment
Recovery orientation
Harm reduction
Active engagement without coercion
Person centred planning
Flexible support for as long as is required.
1 https://housingfirstguide.eu
The pilot service provided a wide range of support,
centred around housing-related help and intensive
case management. Both staff and users spoke about
the holistic nature of the Threshold Housing First
service, led by consumer choice:
Housing First is a wraparound service, its holistic and its tailored to that woman and it can look however she wants it to look and focus on what she wants it to focus on, they can build up a really positive working relationship with the support worker … you can build up that rapport and really achieve things.
(Staff member)
There’s not one thing that I’ve asked for help with and they’ve not helped me, there is nothing that they’ve said no to or I can’t do that, absolutely everything, they are brilliant.
(Service user)
Staff worked with 6-7 customers at one time. The
high intensity of the support was one of the most
valued elements of the support by everyone. There
was a recognition that other services, particularly
statutory providers, did not have enough time to
support the women on a day-to-day basis. The
service was able to offer support with, as one agency
explained, ‘All the bits that hold everything together
really’.
Building successful, trusting relationships was at the
centre of service delivery. Staff also explained how
they were using motivational interviewing
techniques to deliver a strength based approach to
working with women.
… positivity, by saying well done … by just being positive and giving them that confidence, that kind of thing, it makes a massive difference …
(Staff member)
… they are always complimenting, picking out the good things…
(Service user)
3
6
7
16
25
26
29
30
31
0 5 10 15 20 25 30 35
Children's Home
Foster care
Psychiatric ward
Prison
Issues with alcohol
Issues with drugs
Physical health problems
Mental health problems
Experienced domestic…
v | P a g e
The safety of service users was also central, with
daily welfare checks as part of the standard delivery:
I have phone contact every day, even at weekends – welfare checks, I love those welfare checks … because who phones at the weekend to see if you are alright? Nobody. But they d o… It made me feel good that somebody is actually worried about me … it’s amazing … it gives me that little boost every day, I like it.
(Service user)
Staff explained that persistence was key to effective
service delivery, not giving up on people. Service
users stressed the importance of the service being
reliable to them:
They told me that they would get me a property, which they have done; they told me that they would support me, which they have done; that they would get me into education – and I’m getting an apprenticeship in January… a few month ago I wouldn’t have even thought about doing college …
(Service user)
Advocacy was also a central component of the
services, with service users speaking about how the
staff, sometime working well with other key
agencies, had ‘stood up for me’.
They have both [women’s centre and threshold worker] fought for my corner, when I thought there was no-one out there, who’d want to take me on, or want to fight for me, I thought I was just on my own, that I was alone, but now obviously I can say that I’m not, having these ladies around, it’s just been great… there are people out there who do actually care about people like me …
(Service user)
Service outcomes
Housing outcomes
By June 2017, 18 of the 33 women using Housing
First had been found tenancies by the Housing First
service. Twelve tenancies were housing association
properties; six were in the private rented sector. A
further two women had been referred to the service
already living in tenancies (one social; one private
rented sector), but where their tenancy was at risk.
Of the 20 women in tenancies, 16 women were still
in tenancies (including five planned moves within
this) at June 2017, representing an 80 per cent
tenancy sustainment rate. This rate of tenancy
sustainment is similar to the broader evidence on
Housing First in England and in other economically
developed countries, where rates of between 70 to
90 per cent are being achieved.
In addition, three of the 20 housed women had been
supported by the project to move on from tenancies
to live with other family members following
difficulties with living independently. Only one
tenancy was abandoned.
Of the remaining 13 people, three people were
awaiting rehousing and there were ten cases where
the service had signed off the service user before a
formal tenancy offer had been made. Reasons
included: planned move to a care home; being
supported by another housing service; five women
disengaged; three women were returned/recalled to
custody.
Staff working in Threshold Housing First, and other
agencies, all highlighted difficulties in accessing
affordable and adequate housing in Greater
Manchester. Delays in identifying housing was a
barrier to continuing engagement in a number of
cases. However, by mid-2017, the service had
established relationships with four housing
providers, a number of private landlords, and every
landlord in one area - and finding appropriate
accommodation was becoming less problematic.
Staff and users highlighted the importance of
securing appropriate housing for people’s ability to
get on with their lives:
The thing is, when they got their accommodation, they realise they can achieve something … they’ve always wanted to change things in their life, but they’ve not been given that opportunity, because they’ve all exhausted services and resources …
(Staff member)
I’m more settled … I’ve been having a lot of problems going on so it’s like a massive weight off of my shoulders knowing that I am staying put.
(Service user)
vi | P a g e
I have never felt that anywhere has been home, but here, with the help they have given me, just doing things, I’ve got it to how I want it, I’ll never move now, that will be me now. … And I feel safe.
(Service user)
Impact on health and well-being
There was no monitoring data available on changes
to health and substance abuse. However, women
described how the support was helping them to
better manage their emotions, supporting their
mental health generally, and helping them reduce
their anxiety by dealing with problems immediately
and providing support.
Don’t get aggressive with people, don’t get violent, ring me, sound off to me’ and we talk about it the next day … It’s really helped, really really helped, because I am quite aggressive and I lose my temper real quick … with them I can swear and get it all out, and then say thank you! ... I’d be lost without them.
(Service user)
Threshold Housing First staff believed that there had
been some definite changes in women’s mental and
emotional health in the main because the service
could offer an intensive service – this meant that
staff could assist people quickly to decrease anxiety,
stress and worry, and also spend the time needed to
reassure clients and undertake health enhancing
activities like going to the gym and for walks.
The project had supported many women with
domestic violence situations, linking women into
specialist domestic violence services and ensuring
that properties were secure and they had access to
personal alarms. Whilst this was not always
successful first time, many service users explained
that the project (often working with women’s
centres) was succeeding in helping them address
previous domestic abuse in their lives – having a
major impact in terms of assisting them away from
physically and emotionally harmful situations.
There were also examples of people establishing
better relationships with other family members,
however these social outcomes were more varied
and most women were not yet well socially
integrated into their communities. Staff identified a
key need for specialist support or training for staff to
assist women with potentially regaining contact with
their children who had been removed from their
care.
Threshold Housing First staff reported that some
clients had achieved reductions in substance misuse
whilst others were still struggling with substance
misuse issues and not engaging very well with
services. Staff continued to encourage women to
engage with specialist service within the harm
reduction approach of Housing First. Three of the
service users interviewed said that they had given up
alcohol since being with the service, when previously
they were heavy drinkers. A fourth service user
interviewed felt that the support of the project had
enabled them to reduce their alcohol intake.
I feel better in myself as well you know, like I’ve cut down on the beer, they have changed my life to be honest, you know, getting out of [area] and keeping out of trouble …
(Service user)
Offending behaviour
Women who were in sustained contact with
Threshold Housing First appeared to show a marked
reduction in convictions and offending behaviour,
compared to the patterns of conviction they
reported prior to engaging with the service. Only
four women were either returned to prison and/or
committed an offence, during the period for which
they were supported by Threshold Housing First.
Staff felt that the stable base and support, with a
high degree of encouragement and positivity, had
made a difference. Statutory agencies spoke about
how the service was providing ‘protective factors’ via
stable accommodation and getting people out of
abusive situations, and addressing other
‘criminogenic’ risk factors related to reoffending
(such as addressing financial problems).
Conclusion
Threshold Housing First delivered some positive
results in its first two year pilot phase. There was
vii | P a g e
clear evidence that it has provided effective support
that was highly valued by the women using the
service and by partner agencies. There were good
rates of tenancy sustainment for those rehoused,
and although there had been difficulties sourcing
properties, better sourcing of housing was in place at
the end of the pilot.
The research indicates that there is a case for
exploring variants of the Housing First model which
are specifically focused on homeless women with
complex needs. This does not require any change to
the core principles of the original Housing First
model, though some operational modifications, for
example around the management of potential
domestic violence, are necessary.
There is a case for Threshold Housing First to be
integrated into the strategic response to
homelessness across GMCA, where it has the
potential to play a preventative role, deliver relief
from homelessness at a crisis point and provide
sustainable exits from homelessness for women with
high and complex needs.
1 | P a g e
Introduction
This report presents the results of an independent
evaluation of Threshold Housing First by the Centre
for Housing Policy at the University of York.
Threshold Housing First is an innovative service
designed to provide a Housing First service for
homeless women with high and complex needs,
including a history of offending behaviour. This
report explores the first two years of Threshold
Housing First, describing the service, reporting on
the experiences of the homeless women who have
used the service and the outcomes that have been
achieved.
The report draws on qualitative and quantitative
data, collected with free and informed consent,
which were fully anonymised for the purposes of
the analysis presented in this report. The authors’
undertook interviews directly with the women using
Threshold Housing First and with the workers and
managers providing the service, they also talked to
the partner agencies working with Threshold. In
total, 14 interviews were conducted with women
using the service2, four with staff managing and
providing Threshold Housing First and eight with
representatives with partner agencies3. The authors
also asked Threshold to collect some additional data
alongside their standard administrative data. No
individually identifiable data were shared by
Threshold with the authors. Approval for the
research design and methods was provided through
the University of York’s ethical review process.
This first chapter of the report provides a
description of how Threshold Housing First has
developed. The second chapter provides an
2 Eight customers were interviewed in 2016 and six customers in 2017. Two customers were interviewed in both years, so a total of 12 individual women participated in the research.
overview of the experiences of the women who
have used Threshold Housing First and the
processes by which they accessed and engaged with
the service. Chapter 3 is focused on the experience
of the women using Threshold Housing First and the
range of support which they were provided with.
Chapter 4 focuses on the outcomes of the services,
both utilising monitoring data and the views of the
women using Threshold Housing First and staff and
partner agencies. The fifth chapter looks at the
relative cost effectiveness of Threshold Housing
First, exploring the cost to the public finances of
using Threshold compared to standard service
responses for women with complex needs
experiencing homelessness. The final chapter draws
together the key findings and discusses the future
for Threshold Housing First, including the potential
for the service to help reduce sustained and
recurrent homelessness across the Greater
Manchester Combined Authority.
The Housing First Concept
During the 1980s, there appeared to be growing
numbers of homeless people with high and complex
needs, including severe mental illness, in the United
States, Europe and the UK. Policy makers and
service providers tried adapting mental health
service models, used to resettle former psychiatric
patients from hospital into the community, as
means to create new homelessness services for this
group of people.
Mental health services tended to prepare former
psychiatric patients for a new life by providing
support and treatment that was designed to make
3 Eight agency representative were interviewed in July 2017: 4 statutory criminal justice providers; 1 women’s centre; 1 charity working with offenders; 2 housing providers (1 refuge provider; 1 mainstream housing provider).
1. Threshold Housing First
2 | P a g e
them able to manage a wholly, or largely,
independent life. Homelessness services were
designed to follow the same broad approach,
providing access to support and treatment that
would make someone ‘housing ready’ and able to
live as independently as possible. In these services,
housing was only provided once someone was seen
as being able to live a largely or wholly independent
life. As they were based on the idea of homeless
people taking steps towards independent living,
these services were also sometimes known as
‘staircase’ services.
Successes were achieved with staircase services, but
the rates at which people with high needs were able
to sustain an exit from homelessness were variable.
Sometimes, mixed results in ending homelessness
were linked to only limited resources being available
to staircase services4. However, there was also
evidence of homeless people becoming stuck within
staircase services, unable to complete all the steps
required to be offered independent housing.
Homeless people could also move from one
staircase service to another without ever exiting
homelessness5. In some countries, staircase services
had strict rules, which meant that, for example,
being caught drinking or using drugs could result in
instant eviction, reducing the numbers who
successfully used these services. Some homeless
people also left these services before the process of
resettlement was completed because they found
the rules governing behaviour and treatment
compliance difficult to cope with6. This was less
common in the UK, where services tended to have
relatively more flexible and tolerant approaches7,
but there was clear UK evidence of homeless people
with complex needs moving from one homeless
4 Rosenheck, R. (2010) ‘Service models and mental health problems: cost effectiveness and policy relevance’ in Ellen, I.G. and O’Flaherty, B. (eds), How to House the Homeless. New York: Russell Sage Foundation, 17-36.
5 Pleace, N. (2008) Effective Services for Substance Misuse and Homelessness in Scotland: Evidence from an international review. Edinburgh: Scottish Government.
6 Sahlin, I. (2005) The staircase of transition: survival through failure. Innovation 18, 2, 115-136.
7 Pleace, N. (2008) op. cit.
hostel to another and another, at considerable
financial cost, without their homelessness being
resolved8.
The original Housing First service was developed in
New York by Dr Sam Tsemberis9. Housing First
worked in a different way from staircase services.
Rather than being made ‘housing ready’ before they
were provided with housing, homeless people with
complex needs were placed directly into their own
home10 and given access to floating (mobile)
support. Everyone using Housing First had complex
needs, but the original service offered a mix of
intensive case management (ICM), where a Housing
First worker provided direct support and helped
arrange access to other services someone wished to
access, alongside assertive community treatment
(ACT), a multidisciplinary team provided directly by
Housing First for those with the highest needs.
Within New York, in the early to mid 1990s,
research began to show that the new model was
working, as it spread to other cities this success was
repeated, making Housing First increasingly
mainstream in America. The idea of Housing First
started to reach Europe in the late 2000s, although
the first services were not really up and running
until the 2010s. By 2017, Housing First was forming
a core component of the Canadian, Danish, Finnish
and French national homelessness strategies, was
developing in Italy, Portugal and Spain and shifting
from small pilot projects into mainstream
commissioning of homelessness services in the UK,
in cities such as Glasgow, Newcastle and in the
London boroughs11.
The original Housing First service was designed to
work in a specific context, where there was very
8 Pleace, N. and Bretherton, J. (2013) Camden Housing First: A ‘Housing First’ Experiment in London. York: University of York.
9 Tsemberis, S. (2010) Housing First: The pathways model to end homelessness for people with mental illness and addiction. Minneapolis: Hazelden.
10 Or as rapidly as possible, following a short stay in temporary accommodation.
11 http://hfe.homeless.org.uk.
3 | P a g e
little social housing and where access to welfare
benefits and health and mental health services was
determined in part by income, with poor working
age people without children having limited
entitlement to services. This meant that Housing
First, designed to work in New York, was a kind of
welfare state in miniature, directly providing mental
health, drug and alcohol and other services to
service users, who would otherwise not be able to
access this support. As there was little social
housing, the private rented sector was used to
provide settled homes, with Housing First offering a
housing management service to private landlords in
return for taking their service users as tenants12. In
the UK and in Western Europe, Housing First was
being introduced into a quite different situation,
where access to welfare benefits, healthcare and
provision of social housing was much more
generous and extensive than in the United States.
This meant that when Housing First was first
attempted in the UK and in other Western European
countries it often used an intensive case
management model, linking service users to
externally provided services, rather than having a
multidisciplinary team built into Housing First13.
The Housing First Guide Europe14, developed by
FEANTSA, which is a reference point for the Housing
First England: The Principles15 developed by
Homeless Link defines the core elements of Housing
First in the following way:
Housing is a human right
Choice and control for service users
Separation of housing and treatment
Recovery orientation
Harm reduction
Active engagement without coercion
Person centred planning
Flexible support for as long as is required.
12 Tsemberis, S. (2010) op. cit.
13 Pleace, N. (2016) Housing First Guide. Europe Brussels: FEANTSA. There are some important exceptions to this, the national French Housing First programme follows the original model of Housing First quite closely and does
Summarising the Housing First model, it is designed
on the basis that someone is placed as rapidly as
possible in the home they will live in and provided
with support to stay in their home. That support is
highly flexible and is in large part designed by the
service user, the terminology used varies between
countries, but Housing First can be seen as broadly
following the principles of co-production16.
In Housing First, access to housing is not conditional
on behavioural change or compliance with
treatment. For example, someone who is drinking
does not have to stop drinking before they are
housed, nor is their continuing to live in that
housing conditional on their stopping drinking, once
they have moved in. Housing First is not however a
passive service, it does not require people using the
service to show abstinence or engage with support
and treatment, but it emphasises the strengths in
each person using the service and promotes the
idea that positive change is possible. People using
Housing First are encouraged, but are not required,
to pursue a better life, with stable housing, positive
social support, community engagement and
improvements to mental and physical health, being
the core goals. Control ultimately lies with the
service user, determining what support they will
take and what direction they want their life to go in.
Success with Housing First has been considerable.
Across the World, homeless people with high and
complex needs are being rehoused at higher rates
by Housing First than have been achieved by some
previous service models and, in the UK, there is
clear evidence that the early Housing First pilots
were sustainably rehousing homeless people, with
high and complex needs, who had been in hostel
include multidisciplinary (ACT) teams, with a similar model being used in Denmark.
14 https://housingfirstguide.eu.
15 http://hfe.homeless.org.uk/principles-housing-first.
16 http://www.housingeurope.eu/section-47/elosh.
4 | P a g e
systems and experiencing homelessness for many
years17.
Threshold Housing First
Homeless women with complex needs
Since the 1960s, single homelessness among people
with complex needs has been seen as a largely male
experience. Women were present among groups
like long-term and recurrent rough sleepers and
could, like homeless men with complex needs, be in
emergency accommodation and hostel systems on a
repeated basis or for long periods of time, but their
numbers were small. While an increasing proportion
of women was recorded from the 1990s onwards, it
appeared that most single homeless people with
complex needs were men.
Newer research has raised important questions
about this picture of homelessness. There is
evidence that women may often react to
homelessness in a different way to men, relying on
informal means, staying with friends, relatives and
acquaintances, to keep a roof over their head,
rather than necessarily using homelessness services.
There is also some evidence that women were
exhausting their options in terms of staying in other
people’s homes, using up their welcome, before
they approached formal homelessness services.
Most importantly, women living in these precarious
situations, with no housing rights, sometimes little
or no privacy and what can be a risk of abuse or
violence, include homeless women with high and
complex needs18.
The presence of what may be significantly greater
numbers of women within the homeless population
of people with high and complex needs has
implications for homelessness strategy and the
design of homelessness services. However, this is
17 Bretherton, J. and Pleace, N. (2015) Housing First in England: An evaluation of nine services. York: University of York.
18 Pleace, N., Bretherton, J. and Mayock, P. (2016) ‘Long-term and recurrent homelessness among women’ in Mayock, P. and Bretherton, J. (eds), Women’s
not simply a question of numbers. Alongside the
evidence that women may respond to homelessness
in a different way, there are also the questions
around the routes that women take into
homelessness. Among single women with high and
complex needs who experience homelessness, there
is strong evidence that experience of domestic or
gender based violence is extremely high, both in the
sense of the factors directly associated with causing
their homelessness and in their experience of abuse
and violence through their lives. Women’s
homelessness cannot be assumed to simply
replicate male experience. The routes women take
into and through homelessness, their needs, their
characteristics and their experiences are not the
same as for men19.
This raises the question of the extent to which
specific services are required for women. Housing
First is, compared to some earlier service models,
potentially more accessible to women, who are
offered their own, self-contained home and support
that is designed to be highly responsive to their
needs and follow their preferences. Yet it may be
the case that women’s needs are sufficiently
different, on a frequent enough basis, to consider
the development of gender specific services to fully
meet those needs, including the creation of a
Housing First service focused on homeless women
with complex needs.
Homelessness and offending
There is longstanding evidence of associations
between homelessness and offending. In the
context of the UK, there are associations between
repeated small offences and short-term custodial
and community sentences linked to illegal drug use,
mental health and physical health problems,
economic marginalisation and recurrent and long-
Homelessness in Europe. London: Palgrave Macmillan, 209-234.
19 Bretherton, J. (2017) Reconsidering gender in homelessness. European Journal of Homelessness, 11, 1, 1-21.
5 | P a g e
term homelessness20. The relationships are not
straightforward, being in prison for a short sentence
does not ‘cause’ homelessness and being homeless
does not ‘cause’ someone to start committing
offences or to become involved in anti-social
behaviour. However, there is a broad association
between combinations of experiences, which
include addiction, mental health problems and
contacts with the criminal justice system and long-
term and repeated homelessness, for both women
and men21.
Research, policy and practice has emphasised the
importance of residential stability in preventing
reoffending once someone had completed a
custodial or community sentence. A settled home,
community integration and economic integration,
alongside any needs for treatment or support being
met, is regarded as important in preventing
recidivism. Service responses to homelessness,
including Housing First itself, are broadly designed
to achieve something very similar, providing the
stability of a settled home, good social networks
and positive connections to society22.
There have been attempts to use the criminal
justice system to manage levels of rough sleeping
through enforcement, using arrests, fines and
possible imprisonment as a means by which to
reduce visible homelessness. These attempts at
regulation of homelessness through the Police and
Courts, which date back in the nineteenth century
and well beyond, can have a high financial cost. If
homelessness services can play a role in reducing
contact rates with the criminal justice system, there
are potential financial benefits and, in preventing
20 Kemp, P.A., Neale, J. and Robertson, M. (2006) Homelessness among problem drug users: prevalence, risk factors and trigger events. Health and Social Care in the Community, 14, 4, 319-328.
21 Bowpitt, G., Dwyer, P., Sundin, E. and Weinstein, M. (2011) Comparing men's and women's experiences of multiple exclusion homelessness. Social Policy and Society, 10, 4, 537-546.
22 Padgett, D.K., Heywood, B.F. and Tsemberis, S.J. (2016) Housing First: Ending homelessness, transforming systems and changing lives. Oxford: Oxford University Press.
both crime and the experience of homelessness,
clear benefits in enabling often vulnerable people
with complex needs to make a sustained exit from
homelessness.
In some cases, such as in Canada and France,
Housing First programmes have been used to
reduce the financial costs of homelessness to the
mental health and health systems. Alongside
improving outcomes for homeless people, there is
scope for financial savings and the more efficient
use of mental health services, by reducing levels of
homelessness associated with severe mental
illness23. In the Netherlands, Housing First has been
employed as a response to long term and recurrent
homelessness within the context of a wider strategic
initiative to reduce crime and nuisance behaviour,
with the reduction of nuisance behaviour being a
specific goal of Housing First24.
The development of Threshold Housing
First
Threshold Housing First began to be developed
through a collaboration with the Cheshire and
Greater Manchester Community Rehabilitation
Company, which was looking for a new and effective
service that could meet the needs of women with a
history of offending, high and complex needs and
who also had a history of homelessness. Threshold
Housing First represented the first significant
attempt to develop a specialist form of Housing
First, targeted on homeless women who had a
history of offending, in the UK, coming into
operation as more orthodox versions of Housing
First, using intensive case management to work with
23 Goering, P., Veldhuizen, S., Watson, A., Adair, C., Kopp, B., Latimer, E., Nelson, G., MacNaughton, E., Streiner, D. and Aubry, T. (2014) National at Home/Chez Soi Final Report. Calgary, AB: Mental Health Commission of Canada.
24 Wewerinke, D., Al Shamma, S. and Wolf, J. (2013) Housing First Europe. Local Evaluation Report. Amsterdam https://housingfirstguide.eu/website/housing-first-europe-local-evaluation-report-amsterdam/.
6 | P a g e
long-term rough sleepers and homeless people with
complex needs were still being piloted.
At the time of writing, Threshold Housing First as a
service focused on homeless women with high and
complex needs and as a service which is concerned
with reducing contact between people with
experience of homelessness and the criminal justice
system, is unusual and may still be unique. Initially,
Threshold Housing First was a pilot service focused
on Tameside, Stockport and Oldham, three local
authorities that are part of the Greater Manchester
Combined Authority25, a major conurbation in the
North West of England.
Threshold Housing First was designed to support 12
women at a time, using a team of two full-time
workers, one of whom had managerial
responsibility. Over the course of the two-year
period covered by this report, management and
staffing arrangements changed so that the two
workers were both able to carry a full caseload and
a specific part-time manager for the service was also
employed.
There is close collaboration with the Women’s
Centres in Greater Manchester, which are designed
to offer practical and peer support to women with a
history of offending. Threshold Housing First is
designed with close adherence to the philosophy of
Housing First, which means it is shaped – in a real,
operational sense – by the expressed needs and
preferences of the women with whom it works.
As this report details, as Threshold Housing First has
developed and moved towards a steady-state of
operation, it has become apparent that a distinct
form of Housing First service is in the process of
development. The original Housing First, British and
European pilots of Housing First and, increasingly,
the homelessness strategies incorporating Housing
First have been built around a set of expectations
about who homeless people with complex needs
are. That expectation has been shaped by research
and experience derived from working with an
overwhelmingly male population. As we are now
25 https://www.greatermanchester-ca.gov.uk.
starting to learn, our understanding of that
population was incorrect, as women having the
same experiences were less visible than men, rather
than necessarily present at lower rates. A key
difference for women, based on this research and
the experience of Threshold is the presence of both
negative and fractured relationships, with former
partners who were abusive or violent and broken or
weak relationships with children who no longer live
with the formerly homeless women with complex
needs who use Threshold Housing First. Long-term
and repeated homelessness among men, by
contrast, is often characterised by sustained
isolation, by an absence of relationships.
This means that Threshold Housing First is working
in a sometimes different way to other Housing First
services, because it is helping women manage
existing relationships, working to ensure women’s
safety from some current and former relationships
and seeking to help women rebuild some
relationships. By contrast, Housing First services
working with many of the men experiencing long-
term and recurrent homelessness will be attempting
to create social networks for profoundly isolated
individuals. There are shared issues across all
Housing First services, such as working to ensure a
Housing First service user has physical control over
their home and is not within relationships that are
potentially damaging, for example if they are
attempting to manage addiction26, but Threshold
Housing First indicates that there are gender specific
aspects to providing Housing First for women.
Threshold Housing First is now entering a process of
expansion, with the intention being that it will
expand to include more homeless women with
complex needs and work over a larger area of the
Greater Manchester Combined Authority. As this
process of expansion and change occurs over the
next three years, the University research team will
continue to work with Threshold and their partners
to track the achievements of Threshold Housing
First.
26 Bretherton, J. and Pleace, N. (2015) op. cit.
7 | P a g e
Introduction
This chapter draws on anonymised statistical data
collected on women using Threshold Housing First
and the results of interviews with women using
Threshold Housing First, the Threshold staff
providing Housing First and partner agencies. The
first part of this chapter looks at the referral routes
to Threshold Housing First and the second part
explores the characteristics of the women using the
service.
Referrals
Data were available on the women using Threshold
Housing First between April 2015 and April 2017. In
total, 33 women made use of the service over that
period, with 14 open cases at the end of the pilot.
As noted in Chapter 1, Threshold Housing First was
designed to support up to 12 women with high and
complex needs, with experience of homelessness, at
any one point.
Criminal justice related services were the main
referrers to the service. Overall, 49 per cent of
referrals came from Probation, with another nine
per cent coming from other support services for ex-
offenders. The Women’s Centre referrals were also
from services working with ex-offenders, bringing
the total referrals from criminal-justice related
services to 67 per cent (Figure 2.1). Other referral
sources included homelessness services and other
Threshold services.
Figure 2.1 Referral sources for Threshold Housing First (number of women)
Source: Anonymised data collected by Threshold
Perspectives on referral and assessment
procedures
Overall, referral and assessment arrangements
seemed to operate well. Staff reported a strong
demand for the service in all areas, and clearly could
have filled additional spaces on the service had
these been available. Service users did not report
any problems with referral procedures, although
they were not always quite sure about exactly who
and how they were referred. Some explained that
they were nervous meeting new workers but, when
introduced, that they were approachable from the
outset.
Agencies reported that referral and assessment
mechanisms for the project worked well. However,
in one case, there was a long wait between initial
assessment and being allocated a worker. A couple
of people commented that the process and/or
forms were quite lengthy but understood that this
was necessary given the risk profile of the women.
There was just one suggestion for better
0 5 10 15 20
Women's Centre
Homelessness service
Ex offender support service
Other
Other Threshold services
Probation
3
3
3
3
5
16
2. The Women Using Threshold Housing
First
8 | P a g e
information sharing at this stage to reduce the
burden on customers:
Women been through long process and everything is form filling, asking them the same questions and they are quite probing some of the questions, and it can bring up lots of stuff, I don’t know whether another thing maybe data sharing in terms of sharing our assessment forms or something?
(Agency representative)
The Women using Threshold
Housing First
Characteristics
The youngest woman to use Threshold Housing First
was 18 at referral, the oldest was 52. The average
age was 32 and the median age was 30, showing
this was a relatively young group, but not one in
which young women predominated (seven of the 33
were aged under 30 at referral). Almost all the
women using the service (97%) were of White
European origin, all were British citizens and all had
English as their first language.
The majority of the women (79%) were parents, but
none had their children living with them at the point
of referral. Sometimes children were old enough to
be living independently, but interviews showed that
the offending profile of some of the women had
been associated with children being taken into care.
The women were almost all single at the point of
referral (82%) and the small number with current
partners were quite likely to live separately from
them. At referral, all the women using Threshold
Housing First were reliant on welfare benefits, i.e.
no one was in paid work.
Housing situation at referral and
experience of homelessness
The majority of the 33 women who used Threshold
Housing First between April 2015 and April 2017
were recorded as homeless at point of referral (19
27 Bretherton, J. (2017) op. cit.; Mayock, P. and Bretherton, J. (eds) (2016) Women’s Homelessness in Europe. London: Palgrave Macmillan.
women, 58%), with the next largest group being
women about to leave prison with no home to go to
(11 women, 33%). A small group of women were at
risk of homelessness, including risks associated with
domestic violence (3 women, 9%).
The women were living in a wide array of settings
when they were referred to the service. here were
reports of living rough, living in tents, women who
were referred while still in prison or in a Bail Hostel
and evidence of hidden homelessness. Sixteen
different living arrangements were reported by the
33 women.
As noted in Chapter 1, in the UK and internationally,
evidence is indicating the extent to which women
with complex needs may be experiencing multiple
forms of homelessness, particularly hidden
homelessness, which have made them less visible
than single homeless men with high support
needs27. The women using this service were not of
course a representative sample, in part because
referral arrangements incorporated the criminal
justice system and because the numbers were too
small, but the diversity of experience of
homelessness (and risks of homelessness) among a
group of women with complex needs is quite a
striking finding, particularly the extent of hidden
homelessness. A small group of women were living
in refuges at the point they were referred (Figure
2.2).
9 | P a g e
Figure 2.2 Homelessness and living situation at referral (number of women)
Source: Anonymised data collected by Threshold
Self-reported data on homelessness are only
broadly indicative, as memory becomes unreliable
over time and there is evidence that people have
differing ideas about what constitutes a state of
being ‘homeless’. However, while not entirely
reliable as a guide to experience of homelessness,
the reports from the women using Threshold
Housing First indicated that homelessness had often
occurred more than once in their lives. Close to two-
thirds of the women reported they had been
homeless more than twice (58%), while 13 women
using Threshold Housing First reported they had
been homeless once or twice in their lives28. Overall,
the women reported the following:
13 reported they had been homeless once or
twice
11 reported they had been homeless between
three and five times
8 reported they had been homeless more than
five times.
The women using Threshold Housing First were also
asked to provide estimated information on the total
amount of time they had spent in homeless hostels
and temporary supported housing (because they
were homeless). Again, this information is not a
28 Data were not collected for one service user.
precise guide to their experiences prior to using the
service, but gives an indication of what those
experiences were like. Alongside reporting frequent
experiences of homelessness, the women often
reported that they had spent considerable time in
hostels and supported housing for homeless
people29. Eighteen women reported they had spent
two or more years living in these environments
(56%) with another six (18%) reporting periods of
between 18-24 months. Seven women had spent
less than six months in hostels or temporary
supported housing (22%).
Figure 2.3 Self-estimated time spent in hostels and supported housing while homeless (number of women)
Source: Anonymised data collected by Threshold.
Note: Data were not recorded for one service user.
The women using Threshold Housing First were
quite likely to report a history of rent arrears.
Fourteen women had a history of rent arrears, nine
had been evicted because of rent arrears and ten
had current rent arrears at the point of referral.
29 Data were not collected for one service user.
18
64 3 1
24 monthsplus
18-24months
Up to 3months
3-6 months 6-12months
0 2 4 6 8 10
Hidden Homelessness
In custody
Living rough/tent
Supported housing
Refuge
Bail hostel
LA temporary
Hospital
9
8
5
3
3
2
2
1
10 | P a g e
Figure 2.4 History of rent arrears (self-reported, number of women)
Source: Anonymised data collected by Threshold. More
than one response possible.
Experience of statutory homelessness was quite
widespread, with 19 of the women reporting that
they had been found statutorily homeless at some
point in their lives (58%). At referral, nine had
current homeless applications, six of whom were
recorded as owed the Main Duty under the
homelessness legislation that was current between
April 2015 and April 2017 (which will be replaced by
the Homelessness Reduction Act 2017).
Support needs at referral
Threshold Housing First employs a complex needs
assessment scoring system which is completed at
the point someone is referred to the service. The
scoring system focuses on the following areas and is
part of the formal assessment process:
Engagement with frontline services
Intentional self-harm
Unintentional self-harm
Risk to others
Risk from others
Stress and anxiety
Social effectiveness
30 Data were not collected for one woman using the Threshold Housing First service.
31 Johnson, G. and Pleace, N. (2016) How Do we measure success in homelessness services? Critically assessing the
Alcohol/drug abuse
Impulse control
Housing.
A high score in any of these areas denotes a serious
problem and support need30. Someone with poor
impulse control, characterised as having frequent or
severe outbursts of aggressive behaviour receives a
high score on that metric, whereas someone
without any record of such behaviour is rated as
‘zero’ (i.e. has no need in that respect). In respect of
housing, to take another example, a woman
sleeping rough would receive the maximum score, a
woman with settled housing and no related needs
would again be rated as zero. Risks to others or
from others, when severe, are scored more highly
than the other potential support needs, where
these are present.
Criticisms have been directed at scoring models that
attempt to summarise what can be complex and
nuanced patterns of need in a short series of
questions. This is partly because individual need
might not be fully represented, or be
misrepresented, by quite simple indicators and also
because some of these systems can be based on
preconceptions about what characterises homeless
people that may not reflect the reality of their
situation or lived experience31. In this case however,
the complex needs scoring system was employed as
a standardised, initial, proxy measure of support
and treatment needs which was followed by
detailed assessment with the clear emphasis on
personalisation (consumer choice) that defines the
Housing First model, with women enabled to
express their needs in their own way, choosing for
themselves how they were supported and what
services they wished to use32.
One further point is worth briefly noting here, which
is that these sorts of broad assessment systems are,
for obvious reasons, designed to record needs,
rise of the homelessness outcomes star. European Journal of Homelessness, 10.1, 35-55.
32 See following chapter and conclusions.
History of arrears, 14
Evicted for arrears, 9
Arrears in last 5 years, 17
Current arrears, 10
History of arrears Evicted for arrears
Arrears in last 5 years Current arrears
11 | P a g e
rather than individual strengths. It is very important,
as is evidenced in subsequent chapters in this
report, to recognise that homeless people in
general – and the homeless women using this
service in particular – should not be ‘diagnosed’ as
being composed only of a set of support needs,
without recognising that they are complex human
beings who also exhibit strength, capacity and
resilience. Recognition of, and responses to,
homeless people as fellow human beings lie at the
core of the Housing First philosophy33.
The maximum level that someone using Threshold
Housing First can reach on the complex needs
assessment scoring system is 48. The minimum
score is zero, denoting no needs under any of the
headings. The system was designed with a steep
curve. The ‘risk from others’ category moves from
no concerns, rated zero, from ‘minor concerns’
which is rated with as a score of ‘2’, to ‘definite risk
of abuse’ which is rated 4. The highest score out of
five levels is an ‘8’ which is ‘evidence of abuse or
exploitation’. Even a relatively high score is
therefore indicative of significant support needs.
At referral, the women using Threshold Housing
First tended to score fairly highly. The average score
was 31, which was 65 per cent of the theoretical
maximum, with a median score of 30. The minimum
score reported was 24 (50% of the theoretical
maximum and the minimum required for
acceptance onto the service), while the highest was
46 (96% of the theoretical maximum). No trends
were recorded across the different age groups
among the women using the service.
33 Pleace, N. (2016) op. cit.; Tsemberis, S. (2010) op. cit.; Padgett, D. et al (2016) op. cit.
Figure 2.5 Threshold complex needs assessment scores at referral to service
Source: Anonymised data collected by Threshold.
Note: Data were not collected for one woman using the
service.
Self-reported data from the women using Threshold
Housing First confirmed the broad pattern
suggested by the complex needs assessment scores.
Experience of domestic violence was near-universal
(94%), with experience of mental health problems
also being self-reported as very widespread (91%),
as well as physical health problems. Drug and
alcohol problems were also reported by almost all
the women using Threshold Housing First.
Experience of prison was also high (16 of the 33
women). Several women had experience of the care
system as children and seven reported an
experience of staying on a psychiatric ward or unit
(Figure 2.6).
2932
2528
34
29
39
28
34
40
29
35
31
3939
26
32
2624
2629
39
26272825
34
46
25
313433
0
5
10
15
20
25
30
35
40
45
50
0 5 10 15 20 25 30 35
12 | P a g e
Figure 2.6 Self-reported experiences of the women using Threshold Housing First
Source: Anonymised data collected by Threshold.
Note: data were not collected for one woman using the
service.
For the workers and managers of Threshold Housing
First, the complexity of the women’s needs was
often expressed in terms of the circumstances in
which those women had found themselves and
which they continued to experience at different
levels. Women’s needs existed in an individual
sense, because there were issues around mental
health, physical health, addiction and other support
needs, but also in terms of their former, current and
fractured relationships, which often had direct
influence on their well-being, quality of life and
opportunities.
Contact with the criminal justice system
The women who had been supported by Threshold
Housing First had all had contact with the criminal
justice system34. For one group, contact had not
been extensive (eight women had one conviction
each, 24%), but for another group contact had been
repeated (13 women reported more than 10
34 This information was reliable being provided by referral agencies (mainly within the criminal justice system).
convictions each, 39%). This latter group included
women who were described as prolific offenders.
Figure 2.7 Recorded convictions within criminal justice system (number of women)
Source: Anonymised data collected by Threshold.
The women had been convicted of theft and
breaches of court orders, but this was a group of
people who had also sometimes been convicted of
serious offences. A few women had been convicted
of assault and other violent offences, though the
more serious charges of actual bodily or grievous
bodily harm were not widely reported. Fourteen
women had support in place from Probation
services, which is normally employed only when
someone has committed a serious offence and had
been released from prison or let out on license.
The focus of the service on women ex-offenders
who were homeless or at risk of homelessness and
who also had complex needs would be expected to
be reflected in these figures. Among women and
men, longer-term and repeated homelessness is
often associated with mental health problems,
addiction, poor physical health, sustained
worklessness and repeated contacts with the
criminal justice system. As support needs, such as
mental health problems or addiction, can emerge
following homelessness, the interrelationships
3
8
9
13
0 2 4 6 8 10 12 14
6-10 convictions
1 conviction
2-5 convictions
More than 10 convictions
0 10 20 30 40
Children's Home
Foster care
Psychiatric ward
Prison
Issues withalcohol
Issues with drugs
Physical healthproblems
Mental healthproblems
Experienceddomestic…
13 | P a g e
between certain sets of characteristics and long-
term, or repeated, homelessness are complex35.
Summary
There was clear evidence that Threshold Housing
First was working with a group of women who had
all the characteristics of the groups of homeless
people for which Housing First was designed. The
women’s needs were high and complex. They also
had specific needs, for example in respect of
domestic violence and separation from children,
which were different from the patterns of needs
that would usually be expected among long-term
and recurrently homeless men36. As will be
described in the remainder of this report, the
women using Threshold Housing First also had
strengths and capacities, which the service could
enable them and encourage them to use.
35 Pleace, N., Bretherton, J. and Mayock, P. (2016) ‘Long-term and recurrent homelessness among women’ in Mayock, P. and Bretherton, J. (eds), Women’s Homelessness in Europe. London: Palgrave Macmillan, 209-234; Kemp, P.A., Neale, J. and Robertson, M. (2006) Homelessness among problem drug users: prevalence,
risk factors and trigger events. Health & Social Care in the Community, 14, 4, 319-328.
36 Bowpitt, G. et al. (2011) op. cit.; Jones, A. and Pleace, N. (2010) A Review of Single Homelessness in the UK 2000-2010. London: Crisis.
14 | P a g e
Introduction
This chapter explores the use of Threshold Housing
First by the women who were supported by the
service and also details some of their views about
the service. The chapter opens with an overview of
the patterns of service use and then describes the
day-to-day experiences of using and delivering
Threshold Housing First.
Use of the Threshold Housing
First
Duration of support
In total, 33 women had made use of Threshold
Housing First between April 2015 and April 2017.
Nineteen cases were closed (57%) and 14 were
open (43%) as at the end of the pilot period.
Average duration of support was just under eight
months, with a median figure of just over six
months, but the range was considerable, with a few
women not engaging with the service for long, while
others had experienced more sustained support.
The capacity of the service was 12 women37,
meaning the service was operating a little above
capacity, with 14 women receiving support. Housing
First services can operate slightly above nominal
capacity when their caseload includes people who,
while they still require the service, have reached a
steady state where they are increasingly managing
on their own. This allows a Housing First service to
manage a nominally somewhat larger caseload,
because some people are reaching the end of the
time when they will require Housing First. Equally, a
37 See Chapter 1.
new Housing First service may need to build up to
full operating capacity, because everyone will be a
new, high-need, service user requiring intensive
support, meaning that, initially, everyone may
require the maximum possible support38.
Current cases tended to have been supported for
longer than closed cases, with an average of nine
months of support and a median of seven months.
Just over half of current cases had been supported
for more than six months. For closed cases, the
figures were just under seven months of support on
average, with a median of just under six months.
Almost two-thirds of closed cases had been
supported for six months or less.
Of the 19 women who had engaged with Threshold
Housing First between April 2015 and left the
service before the end of April 2017:
Eight had made planned moves on from the
service. Half of this group had reached a point
where they were living independently, others
had ended their service use in a planned way
(for example they were moving away from
Greater Manchester).
Three women opted to end their support from
the service.
Three women committed offences and were
returned to prison.
Four women broke contact with the service.
One woman using the service died.
All Housing First services are characterised by
attrition and by graduation. Attrition refers to the
loss of service users who either choose not to
engage with Housing First for very long, or whose
38 Tsemberis, S. (2010) op. cit.; Pleace, N. (2016) op. cit.
3. Using and Delivering Threshold
Housing First
15 | P a g e
use of the service comes to an abrupt and
unplanned end. Graduation, of course, refers to
someone who had reached a sufficiently stable
situation to mean they can live independently
without continued support from Housing First,
though they may still require some housing-related
support from lower intensity services, such as a
tenancy sustainment service.
On current evidence, attrition rates from Housing
First services are in the 30 per cent to ten per cent
range, depending on the specific needs of the
people they are working with, their resources and
the contexts in which they are operating. A good
rule of thumb is that Housing First services typically
house about 80 per cent of their service users for at
least one year39, although results from a 2014/15
analysis of pilot Housing First services in England
suggested a slightly lower figure of around 75 per
cent40.
By contrast, graduation from Housing First services
appears to be quite an unusual event, with
sustained patterns of service use being more of a
normal outcome. In part, this is because a lot of
Housing First, in the UK, in Europe and North
America, is still quite new. In some senses we are
still unclear what the long-term outcomes of a
Housing First programme are, because a lot of these
services have yet to be operational for as much as
five years. Some of the research that is available
shows graduation can occur, but that people may
continue to use Housing First for quite long
periods41.
One difficulty in assessing the engagement that has
happened with Threshold Housing First is that there
is no real framework for comparison. As our
understanding of the distinctiveness of women’s
experience of homelessness starts to grow, it is
becoming apparent that comparing a Housing First
39 Pleace, N. (2016) op. cit.
40 Bretherton, J. and Pleace, N. (2015) op. cit.
41 Padgett, D.K. (2007) There's no place like (a) home: ontological security among persons with serious mental illness in the United States. Social Science and Medicine, 64, 9, 1925-1936.
service, which works with both genders or which is
focused more heavily on men, with Threshold
Housing First may not be valid, as like is not being
compared with like42. It is not clear what should be
expected from a Housing First service focused on
women, or indeed which engages specifically with
former offenders, because there is little to directly
compare such a service with. This is a very high
need group of women43 who may collectively
represent a higher and more complex combination
of needs than the pilots of Housing First in the UK
typically deal with, even though these services are
also working at the upper end of complex needs
with the homeless people they are engaging with44.
Assessing what Threshold Housing First has
achieved to date and drawing a broad comparison
with other Housing First services, both in the UK and
internationally, three points can be made:
There may be a higher rate of attrition than for
some other Housing First services.
However, Threshold Housing First appears to
achieve ‘graduation’ for the women using the
service at a more rapid and frequent rate than
some other Housing First services are able to
achieve.
There was evidence of sustained contact
between Threshold Housing First and homeless
women with high and complex needs, nine
women had been supported for a year or more,
another five for over six months.
The support provided
As with any Housing First service, Threshold Housing
First provides a defined range of support, centred
around housing-related help and intensive case
management. Unlike some earlier service models,
there is a high degree of what was originally termed
consumer choice, which can be broadly defined as
42 See Chapter 1.
43 See Chapter 2.
44 Bretherton, J. and Pleace, N. (2015) op. cit.
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reflecting the principles of personalisation and co-
production, in how Housing First is delivered.
Service users do not receive the same, standardised,
package of support, because they play the central
role in determining what that support is. For the
women using Threshold Housing First, the mix of
support they received centred around four main
areas:
Housing sustainment
o Daily living skills o Management of finances and debt
Health and wellbeing
o Mental health o Physical health o Addiction
Social integration
o Avoiding anti-social behaviour o Avoiding criminal activity o Engagement in education, training,
volunteering and employment
Social Networks
o Positive relationship with a partner o Positive relationships with children o Positive relationships with family and
friends o Positive relationships in the
neighbourhood
Chapter 4 describes the outcomes achieved by
Threshold Housing First in respect of these different
outcomes. The remainder of this chapter outlines
the key elements of the service begins by outlining
perspectives of staff and agencies on the type of
support provided, followed by detailed reflections
from the women being supported by Threshold
Housing First on the service they were receiving.
Staff and Agency Views on
Service Delivery
Threshold Housing First staff spoke about the
holistic nature of the Threshold Housing First
service:
Housing First is a wraparound, its holistic and its tailored to that woman and it can look however she wants it to look and focus on what she wants it to focus on, they can build up a really
positive working relationship with the support worker, ‘you said you were going to do that and you did do that for me’ … you can build up that rapport and really achieve things.
(Staff member)
Staff also spoke about the intensity of support as
being key to service delivery. They were able to
work with 6-7 customers at one time and offer a
very responsive service to customers. Building
successful, trusting relationships was at the centre
of service delivery. The service was as customer led
as possible, with a daily welfare check as standard
to ensure the safety of women:
… building relationships, that’s very important as a lot of these women have not had that from people or organisations … it is very different from anything they have come across and many of these women will have had lots of different sorts of rejections, lots of sort of doors closing, no, no, no, we don’t want to know if you are going through a low week or a low period, whereas with us that is absolutely fine, you don’t want to see us this week or next week, that’s absolutely fine … we will still be contacting you every day to make sure you are okay, and that is fundamental in how successful this is, they don’t get that anywhere else.
(Staff member)
Being persistent was also key to service delivery:
That’s what really stands out, what is the really positive thing that we do is: Persistence, persistence, persistence, we keep chipping away ... We don’t give up.
(Staff member)
The service wanted to ensure that their customers
felt valued. This was seen as essential for people to
start believing in themselves:
They’ve got people … but they are not there, no-one gives, no-one cares, no-one supports and it is that attitude, we are here for you, it’s about you this, we are going to get you a roof over your head, and we are then going to start looking at what needs getting addressed and what you want to be doing, valuing them I suppose, whereas they might never have had that, or had that kind of feeling, even if they’ve had their own social worker, the state of social care, you don’t get that quality time ... it’s the support really that makes
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them want to stay with us … if they need us for 7 hours a day we are going to be there … it’s there every day if you want it …
(Staff member)
Staff also explained how they were using
motivational interviewing techniques to deliver a
strength based approach to working with women. It
was crucial to stress people’s potential, rather than
limitations stemming from traumatic past
experiences:
… positivity, by saying well done, bigging them up, as they’ve probably never had it … by just being positive and giving them that confidence, that kind of thing, it makes a massive difference …
(Staff member)
Agencies spoke very highly of the support provided
by the Threshold Housing First services. The high
intensity of the support was one of the most valued
elements of the support. There was a recognition
that other services, particularly statutory providers,
did not have enough time to support the women on
a day-to-day basis with tasks such as accessing GPs,
other health services and helping them manage
their tenancy. The service was able to offer support
with, ‘All the bits that hold everything together
really’. The daily welfare checks were also felt to be
incredibly valuable:
The part of the service that I found really good was that they rang them every day, and the women really really took to that, a few of mine just said it’s really nice, I know that I’m going to get that call today and someone cares ... I didn’t find many of the women didn’t respond to that … they could say that they were having a good day, as well as when having a bad day and could off-load. … Rather than getting to a crisis …
(Agency representative)
Agencies also praised the service for adopting a
client-led approach to service delivery. The service
was able to work closely with women to identify
possible activities and opportunities that could
enrich their lives and well-being.
It’s an absolutely fantastic service. … We do the things that needed to be done from a risk management perspective, they would also take on
the women’s perspective of what they want, it was very client led ...
(Agency representative)
The Threshold Housing First service was also felt to
offer a good balance between offering support to
women but being sensitive not to create a
dependency on them. The service was also seen to
be offering ‘appropriate’ levels of support over time
to meet increasing or reducing need.
Joint working
Project staff described a highly networked system of
joint working in the three local authority project
areas. They described close working relationships
with statutory providers, women’s centres, a range
of homelessness and third sector providers,
specialist alcohol and substance misuse services and
housing providers (both social and private
landlords). Staff felt that good inter-agency working
arrangements, including sharing of information, had
been established.
Without exception, the agencies interviewed for the
evaluation confirmed that there was excellent joint
working arrangements between themselves and the
project. They explained that there was a lot of
communication between them, and also other key
providers, to ensure that the best possible support
was available for women. Sometimes, joint
appointments were used at key points in service
delivery (for example, when a property was found),
and also to re-engage users for one agency or
another. It was also reported that there was
effective joint working at times of crisis, with the
Housing First service responding quickly. Co-location
of services further enhanced communication, for
example where Housing First delivered the service
from local women’s centres.
We just seem to have gelled … we will text and email each other and keep each other in the loop … I think they communicate really well … I’ve just found them brilliant, I really have, I can’t praise them enough …
(Agency representative)
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One housing provider described a shared
information protocol that they had in place with the
service, and really appreciated having a ‘named
contact’ with the service.
Using the Threshold Housing
First Project: The Views of
Women
A comprehensive service
Customers explained that the project assisted them
with all aspects of their lives:
There’s not one thing that I’ve asked for help with and they’ve not helped me, there is nothing that they’ve said no to or I can’t do that, absolutely everything, they are brilliant. Things they help me with … my housing, bills, debts, anything like, if I’m low on money and I need a food parcel, they will help me out with that, any forms, going to the doctors with me, anything I need help with, I can ask her and she will help me with. If it’s anyway impossible, she will work around it and we’ll get it done.
(Service users)
Women described a very ‘hands on’ service, which
offered lots of practical help. Assistance included:
Finding and furnishing accommodation
Helping to decorate their accommodation
Helping sort out bills and benefits
Buying food/ meals (including shopping)
Getting food parcels
Buying clothes (including shopping)
Buying a mobile phone
Attending activities/ meetings with them (for
example, women’s centre/ drug services)
Open bank accounts
Register with doctors/ dentists
Helping with contact with children
Helping make house secure from violent ex-
partners
Sort out medication/ health matters
Accessing courses
Accessing the gym
Going for walks or to local places like museums.
Without exception, the women using the service
described this practical support as very helpful to
them:
... She has helped me get some clothes, because I had nothing ... she’s helped me sort my benefits out, she is helping me decorate my flat, she’s got an award for me
She also bought me a mobile phone as well which has been a really big help so I could get in touch with people, doctors, benefits, that’s been a real big help.
(Service users)
Women also described a project that offered them
considerable emotional support. This support was
hugely appreciated by the women, not least
because many women had such little support in
their past and present lives.
I don’t have many people in life but [the worker] is one of them … I’d be pretty in the shit if not … … it’s fair to say that she has been there more for me, in the past four month, than my mum has in my entire life. I don’t look at her like a mum, but she is just somebody who has supported me like my own family should have done, really.
(Service user)
Very few women could think of how the service
could do anything further for them. The first interim
report highlighted a request for counselling support
and more help with leisure activities such as
swimming. In the second round of interviews, one
of the women would have dearly loved to be able to
horse ride (and a second was hoping to train in
horses); this area may be worth investigating in the
future. A couple of users also suggested that it
would be good if the project allowed them to travel
in the worker’s cars (something also raised by one
agency).
Frequent/available service
The majority of women in 2016 and 2017 described
a high level of contact with project staff. Daily
contact by phone was standard, with face-to-face
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varying according to how often they wanted to see
workers. Service users appeared unanimously happy
with the level of support, receiving enough support
but also not too much support.
The frequency/intensity of the service was higher
than other services that people were in contact with
or had been contact with in the past – and was
preferred by users.
You go in and have a chat with your probation officer and see how you are and how you are doing and everything… but these are more better because you see them near enough every day like, well I do, and I’ve got their numbers and everything, they have just said, ‘If you need anything, just give us a ring’… I prefer talking to these than the probation officer, obviously, you know. She will take the time out of her weekend or watching the soaps at night, she will take the time out, an hour or half an hour, to ring me, to see how I’m doing – that is really good that. Cos I have been with a few different agencies before, that were a bit like this but they were rubbish, they were a lot worse, they never rung me on a weekend just to see how I’m doing and stuff like that, that’s really good.
(Service users)
The daily welfare checks appeared to be really
appreciated as it showed that the workers really
cared about them, as one woman explained, ‘you
know that they are still thinking about you’. Another
woman said:
I have phone contact every day, even at weekends – welfare checks, I love those welfare checks … because who phones at the weekend to see if you are alright? Nobody. But they do … It made me feel good that somebody is actually worried about me … it’s amazing … it gives me that little boost every day, I like it.
(Service user)
A reliable service
In part due to the nature/intensity of the service,
and in part due to the professional commitment of
the workers employed, women stressed the
reliability of the service – it was available to them
when they needed it, for whatever they needed.
Where workers were busy, they got back to
customers as quickly as possible. They also actioned
support as quickly as possible. In short, women felt
they could rely on – and trust – Threshold Housing
First to support them. From the perspective of staff,
this meant that they “did not give up” on the
women using the service.
They told me that they would get me a property, which they have done; they told me that they would support me, which they have done; that they would get me into education – and I’m getting an apprenticeship in January… a few month ago I wouldn’t have even thought about doing college …
(Service user)
One woman described how this kind of reliability of service was rare in her experience. This woman felt that she had been let down by a range of services, including Probation, her CPN and workers in supported accommodation. The tenacity, competence and reliability of Threshold Housing First spoke to women’s self-esteem – there was an unspoken understanding that the women’s lives mattered. It also enabled the service to be very responsive to women’s needs.
They always get back to me, a lot of services where they say we will do this, we will do that, you just get passed from pillar to post – but when they say they are doing something, they do it … I’ve had a really hard life and nothing has ever been seen through, basically, but with them, they have. … They have not let me down once … I’ve been passed around from pillar to post, no-one has really helped me at all … they pass you to one person and that person will work with you, and they will leave and another person will come along, and you end up explaining it all again, then they say they will do this and then 3 weeks later you are on the phone and asking if anything has been done and they are like, ‘Oh, I’m just getting round to it’ …
(Service user)
Another woman explained:
[the worker] has never once failed. It’s like there are 10 [worker’s name] … everything is consistent, she won’t just do something and then it gets left for a bit, it’s constant, because we have everything on my plan, and we go through everything every single week.
(Service user)
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In quite profound ways, the Housing First workers
were almost offering the support of a parent or
guardian, providing the consistent and constant
support needed to ensure that women felt safe,
valued and supported going out into the world. As
described earlier, many women had very difficult
childhoods, as well as adulthoods, and found it very
difficult to trust others, possibly as a result of
insecure attachments in childhood. It was really
important that the service was able to offer
consistent and ongoing support to women. Some
women had often experienced multiple rejections
and been abandoned in the past. One woman told
us how the service had told her, ‘I won’t abandon
you, it’s you that’s got to abandon me, you’ve got to
sign me off. … Basically I thought I was worthless
and now I now I’m worth it’.
Unfortunately, there had been a change in staff
after one year and some service users had found
this hard, even though the service tried to transition
this carefully and explain the reasons why.
I’m not picking on [previous worker], but I feel like she has distanced herself from me … I know she had got a lot going on, but to me it’s like, when I needed you most, you have gone and left me, but she doesn’t actually work for them now, I think that is the reason why …
(Service user)
A ‘positive’ advocate approach
Women felt that the Threshold Housing First service
were very positive with them and about their
future.
… they are always complimenting, picking out the good things …
(Service user)
At the same time, women described a service that
whilst positive, was also honest and straightforward
with people:
… they are very straightforward, don’t beat around the bush, tell you how it is, they don’t leave you dangling …
They don’t bullshit you… and they don’t talk down to you.
(Service users)
Service users described how the workers acted as an
advocate or champion for the women. One woman
explained how they had ‘stood up for me’. Another
woman very eloquently and emotionally described
how she felt that the service - working with the
women’s centre - was on her side:
They have both [women’s centre and threshold worker] fought for my corner, when I thought there was no-one out there, who’d want to take me on, or want to fight for me, I thought I was just on my own, that I was alone, but now obviously I can say that I’m not, having these ladies around, it’s just been great… there are people out there who do actually care about people like me …[she cries]
(Service user)
Choice and control
Service users spoke highly of a service that gave
them as much choice and control as possible, also
comparing favourably to other services which
(sometimes for statutory reasons) were highly
directive:
They tried pushing me to do it, the [YOT] worker, they tried saying, [name], you’re doing this, you are doing that, and it was like, I’m not. These are like, you can do it, these things are there if you want it, just take it if whenever you want it … I think they know me here, for four month(s). I knew my YOT worker for eight nine months but she didn’t know me. They have actually took time out to get to know me and stuff, and that’s good.
(Service user)
Some service users struggled with self-direction, but
felt that the workers had the right approach in
explaining and facilitating options:
I don’t have a clue sometimes what to do or who to go to, or what I need to be doing, and I don’t know, they put everything into place, I know you shouldn’t have everything done for you, but they do it with you, they explain things … not ‘get this done!’ … it really helps… they are not overbearing…but they will teach you.
(Service user)
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Another user felt that she also needed direction and
appreciated this, and felt that their confidence was
teaching her how to lead in the future:
… being told what to do, in the right way, with confidence, do you know what I mean, it’s really good … with people who have got a bit more zazz about them, they draw you in a bit more … strong character produces strong followers, once you have been a follower, you become a great leader don’t you, you’ve got to be a follower before you get to be a leader don’t you, and if you’ve got someone good to follow, then you have cracked It … people like me who have been in foster care all their life, who don’t really have that support, this service really gives you that kind of base kind of thing.
(Service user)
Central to both a strengths based and customer-led approach was respect for the project’s customers and a willingness and ability to really listen to women – both about their circumstances and their priorities for the future. It appeared this was being achieved with empathy and, crucially without judging people. The same customer who explained the workers had ‘fought [her] corner’ explained the importance of this:
When she came to visit me the first time, her sitting, her sitting with me and actually listening to my story, that were the most helpful because she took it all on board … she sat there and listened to ME, and not judged me – like other people who I’ve been to see, I feel like they are judging instead of listening to me, and she wasn’t like that … and she took everything on board and that’s what she has worked off and it has just been brilliant, her support and how much she has taken the time out for me really – she is really good because she has took the time out for me and no-one ever does that for me.
(Service user)
45 Pleace, N. (2016) op. cit.; Busch-Geertsema, V. (2013) Housing First Europe: Final Report. Bremen/Brussels: European Commission https://housingfirstguide.eu/website/wp-content/uploads/2016/03/FinalReportHousingFirstEurope.pdf
46 Nelson, G., Aubry, T. and Lafrance, A. (2007). A review of the literature on the effectiveness of housing and support, assertive community treatment, and intensive
Fidelity with the Housing First
Model
There was clear evidence that the Threshold
Housing First was following the core philosophy of
the Housing First model. Women were exercising
real choice and control over the support they
received with a positive and non-judgemental
framework of service provision that respected their
opinions and responded positively to their needs.
The degree to which exact fidelity with the original
model of Housing First, which had been copied
closely in some countries like Canada and France,
but modified in other contexts, including the UK, is
still being debated. Three areas of discussion exist.
One is whether or not the original model’s use of an
in-house multidisciplinary team, including dedicated
drug and alcohol specialists, peer mentors, mental
health and medical professionals who work for
Housing First is required outside the USA, where
welfare and health systems are more broadly
accessible (the US has no equivalent of the NHS for
example). UK services, in common with those in
some other countries45, have tended to deliver
Housing First as an intensive case management
service only, with workers providing some direct
support, but facilitating access to the treatment,
support, housing related services, education,
training and other services that people accessing
Housing First choose to use. There is clear evidence
that Housing First services which do incorporate
multidisciplinary teams are effective, from
Denmark, France and Canada, as well as the USA46.
However, some systematic and large scale Canadian
research has reported that intensive case-
management versions of Housing First may have
similar levels of effectiveness47, while the smaller,
case management interventions for persons with mental illness who have been homeless. American Journal of Orthopsychiatry, 77, 3, 350-361; Pleace, N. and Bretherton, J. (2013) The case for Housing First in the European Union: a critical evaluation of concerns about effectiveness. European Journal of Homelessness, 7, 2, 21-41.
47 Stergiopoulos, V., Gozdzik, A., Misir, V., Skosireva, A., Connelly, J., Sarang, A., Whisler, A., Hwang, S.W.,
22 | P a g e
less robust, UK and European evidence base
suggests the same broad finding48.
Another area of discussion centres on whether
housing should be ordinary self-contained flats and
houses, or whether it is acceptable for people using
Housing First to live in congregate and communal
settings. This has not really been an issue in the UK,
because the statutory homelessness system and
other services have always sought to provide
ordinary housing as the solution to most
homelessness, hence Housing First services use
ordinary, self-contained, scattered housing49. In
Europe and the USA, some congregate Housing First
services (blocks of flats where everyone is a Housing
First service user) exist and there are debates about
whether this enables formerly homeless people to
become socially integrated in the same way as if
they live in the community50.
Another area where Housing First services can differ
is in the extent to which they employ peer support,
the use of what are sometimes referred to as
‘experts by experience’ (people who have
experienced long-term and recurrent homelessness)
as peer support workers and sometimes as front-
line staff. Broadly speaking the evidence base on
using peer support, which is a part of the original
Housing First model, is positive, but it is also
somewhat incomplete, there being a lack of clarity
about what the specific benefits may be and at what
level peer support should be used in order to be
beneficial. This was an aspect of Threshold Housing
First that was still under development during the
period covered by this report.
Taking the Housing First Guide Europe51 as a
reference point, which is the basis for Housing First
England: The Principles developed by Homeless Link,
O’Campo, P. and McKenzie, K. (2015) Effectiveness of Housing First with intensive case management in an ethnically diverse sample of homeless adults with mental illness: a randomized controlled trial. PloS one, 10, 7, p.e0130281.
48 Busch-Geertsema, V. (2013) op. cit.; Bretherton, J. and Pleace, N. (2015) op. cit.
Threshold Housing First can be assessed against the
following list of core components of Housing First52:
Housing is a human right
o Threshold Housing First follows this approach, seeking to provide suitable, independent housing as quickly as possible to the women it supports.
Choice and control for service users
o The delivery of the Threshold Housing First service supports this principle.
Separation of housing and treatment
o This is also an intrinsic part of the design of Threshold Housing First.
Recovery orientation
o This aspect of Housing First, supporting people to believe positive change is possible and to recognise their own strengths, is integral to the service.
Harm reduction
o Threshold Housing First follows a harm reduction approach in relation to drugs and alcohol.
Active engagement without coercion
o This aspect of Housing First centres on positive engagement with people using the service and is part of the Threshold approach.
Person centred planning
o Again this is an integral part of the Threshold approach.
Flexible support for as long as is required
o This principle was challenging with respect to the development of Threshold Housing First which had time-limited funding, but the future of the service is now looking more secure (see Chapter 6).
49 Bretherton, J. and Pleace, N. (2015) op. cit.
50 Quilgars, D. and Pleace, N. (2016) Housing First and social integration: a realistic aim? Social Inclusion, 4.4, DOI: 10.17645/si.v4i4.672.
51 https://housingfirstguide.eu.
52 See also Chapter 1.
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Summary
The level of engagement with Threshold Housing
First could be variable, with some women opting
not to take up the service, while others were unable
to sustain contact because of external factors.
When the service was taken up and contact was
sustained, the quality and range of support on offer
tended to be regarded very positively. Women were
often highly impressed by the services they were
receiving and the workers delivering Threshold
Housing First had a positive view of what they were
achieving, as well as agencies that they were
working with. While some questions around the
importance of fidelity to the original American
model in the delivery of Housing First are still not
entirely resolved, Threshold Housing First was
clearly following the core philosophy of Housing
First and was compatible with working UK and
European definitions of what a Housing First should
be.
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Introduction
This chapter explores the trajectories of the women
using Threshold Housing First, reporting on the
outcomes that were achieved. The chapter opens
with analysis of the anonymised data collected on
outcomes, looking at exits from the service, housing
outcomes and changes around health, well-being
and social integration. The achievements of the
service are also explored in more depth with
reference to the interviews with women using
Threshold Housing First, with the Threshold staff
team providing and managing the service and from
the perspective of partner agencies.
Housing Outcomes
Housing sustainment
By June 201753, 18 of the 33 women using Housing
First had been found tenancies by the Housing First
service. Twelve tenancies were housing association
properties; six were in the private rented sector. A
further two women had been referred to the service
already living in tenancies (one social; one private
rented sector), but where their tenancy was at risk.
The main measure of success in Housing First
projects is the proportion of people housed who
remain stably housed on an annual basis/ at the end
of the evaluation. This measure allows for any
planned housing moves where people move to
another more suitable tenancy.
Of the 20 women in tenancies, 16 women were still
in tenancies at the end of the evaluation (6 of these
were closed cases (average of 9 month’s contact);
10 still open (average of 8 months). This represents
an 80 per cent tenancy sustainment rate. This rate
53 Data on housing outcomes was available for a slightly longer pilot period (until June 2017), whilst data on referrals only reported until April 2017.
of tenancy sustainment is similar to the broader
evidence on Housing First in England and in other
economically developed countries, where rates of
between 70 per cent to 90 per cent are being
achieved, usually summarised as a rate of about
eight out of every ten service users.
Five of these 16 women had made planned moves
over time. This included two moves from the private
rented sector to a social rented tenancy, and one
move where the first tenancy was not suitable to
meet the person’s needs associated with a
disability.
In addition, the project reported that three of the
20 women had been supported by the project to
move on from tenancies to live with other family
members following difficulties with living
independently (all closed cases). For example, one
woman was supported to move in with her brother
following neighbour complaints and domestic
violence at the property. Another had been a target
for domestic violence in the community and chose
to move in with her mother and son. A third was
supported to move in with her mother following
breaches of her order whilst living in the tenancy. In
these cases, the women did not become homeless
again in terms of rough sleeping or living in
temporary accommodation.
Only one tenancy was abandoned. The client
abandoned the tenancy and lost contact with the
service (closed case).
4. Outcomes
25 | P a g e
Other housing outcomes
As reported above, 20 of the 33 women had been
housed (or helped to sustain tenancies) over the
course of the evaluation.
Of the remaining 13 women, three women were
awaiting rehousing. One person was living in a care
home for older people, another was in custody and
one was living with relatives awaiting housing.
In addition, there were ten cases where the service
had signed off the service user before a formal
tenancy offer had been made. This was for a variety
of reasons, including both positive and not so
positive outcomes:
One woman made a planned move to a care
home arranged by a hospital team.
Another woman chose to be referred to another
service for housing.
One woman declined support whilst living in
temporary accommodation.
One woman disengaged and sadly died (was of
No Fixed Abode).
Three women disengaged whilst living with
family or partner.
Three women were returned/recalled to
custody (two from living with family).
Housing quality
Nine women who had been housed in the social
rented or private rented sector chose to share their
opinions of where they were living with Threshold
Housing First staff as part of the monitoring:
All of the women in social housing were either
fairly (four women) or very satisfied (two
women) with their current home.
Of the three women in the private rented
sector, two were very satisfied and one
reported that she was ‘not at all satisfied’.
The women in social housing reported they felt
physically safe all or most of the time.
One woman in private rented housing reported
not feeling safe, the other two reported feeling
safe most of the time.
All the women in social housing reported that
they felt in control of their home, as did two of
the three women in the private rented sector.
All the women in social and private rented
housing reported that they would ‘be sorry if I
had to leave here and move somewhere else’.
All the women in social rented housing and two
of the women in private rented housing
reported that their home made them feel they
were ‘doing well in life’.
The women in social housing reported that they
could do ‘what they wanted, when they wanted’
in their homes, which was also reported by two
of the women in the private rented sector.
All the women in social and private rented
housing reported they could ‘get away from it
all’ in their homes.
Space standards in both social and private
rented housing were described as sufficient with
the exception of one woman living in the private
rented sector.
All the women in social housing described their
homes as in ‘good condition’ as did two of the
women living in the private rented sector.
All the women in both the private and social
rented sectors reported that they could afford
the rent and the utility bills, also reporting that
after they had paid the rent there was ‘enough
money left to live on’.
These findings indicated that when women had
been placed in settled housing by Threshold
Housing First, outcomes in terms of the quality and
safety of the housing were often good, if not always
entirely perfect. The women using the service, who
had been rehoused, were often positive about their
homes. They explained that the properties were in
good condition and were either furnished or the
project had helped them to furnish the property.
It’s a bedsit but its fully furnished, newly decorated, new carpets, new blinds, it’s really nice.
(Service user)
The location of the properties was very important to
service users. A number of women described how
they were relieved to be living away from where
26 | P a g e
they previously lived for safety reasons in the case
of domestic violence and/or being away from wider
negative influences of peer groups and problems
associated with poor neighbourhoods. As described
in the next chapter, a couple of users had to make a
subsequent move to escape partners following
them, but this was achieved and they were very
pleased with the new properties. Threshold Housing
First appeared to have succeeded in finding people
properties in quiet neighbourhoods.
In most cases, women accepted the first property
they were offered. Whilst they tended to have little
choice over the type of accommodation being
sourced, people were quite happy with this as long
as the location and condition of the housing was
suitable. The women had quite modest aspirations
that centred around crucial concerns related to
safety, comfort and refuge. One service user
interviewed was not happy with her housing in the
private rented sector; she really wanted to move
into a Threshold property (especially as she had
been housed in the past by them and had been
impressed by both the accommodation and
support). A second was living with family members
waiting for rehousing and found this situation very
hard.
Threshold Housing First staff also reported that
some of the properties sourced were of quite a high
standard whilst there were one or two that they
really did not feel were suitable for people’s needs.
In one current case, they explained they were trying
to get a person moved to a new property. Where
housing was found, agencies reported that this was
usually of a good standard and customers were
happy with the properties. One property was
reported to be a ‘lower level of habitable property’,
having some problems with electrics and with a lack
of furniture and curtains, however the respondent
went on to explain how the Threshold Housing First
helped sort out all these problems quite quickly.
Securing housing
Perspective of staff and other agencies
Staff working in Threshold Housing First, and other
agencies, all highlighted difficulties in accessing
affordable and adequate housing in Greater
Manchester. A shortage of housing was a general
problem, with customers with complex needs and
often failed tenancies in the past, finding it almost
impossible to access housing without specialist
assistance.
However, over time, Threshold Housing First had
established relationships with housing providers. By
mid-2017, they were working with four housing
providers (three offering two properties per year
and one offering four properties per year) and a
number of private landlords, as well as an
agreement with every landlord in one of the three
areas. The interim report noted considerable early
success in accessing properties. However, it
appeared that there were greater difficulties in
accessing housing in the second year of the project,
with some customers having to wait a number of
months for housing. Due to these delays, the service
made a decision to offer support to women who
were waiting for housing, as they felt it was unfair
not to do so, although they acknowledged that the
ideal model would be to secure housing almost
immediately and offer support alongside this.
Agencies also identified the wait for housing for
some customers as the biggest challenge of the
service in 2017. For example, one provider
explained that they were supporting one of their
clients who was currently sleeping rough but they
were waiting for accommodation to be found. This
agency representative was also trying other avenues
to house their client. Another agency explained that
the project seemed to find properties quite quickly
in its first year but then the source seemed to dry up
– they explained it was hard to keep clients engaged
at this point and they had sometimes taken women
off the service to get them a place somewhere else.
Another agency reflected that the service was still
undertaking intensive work with one of their clients
whilst awaiting housing waiting for housing.
Housing … that is the one problem with the service … they didn’t seem to have access to actual properties … I could have referred all my caseload into them practically!
(Agency representative)
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I think it would be great if there were more properties available … because the staff are willing to do the work and usually the clients are willing to put their bit in too, it’s just having the facilities there, the actual house and stuff.
(Agency representative)
I believe that they do really good work but their hands are tied awaiting on properties …
(Agency representative)
Perspective of service users
In the first year of the service, customers were often
amazed at the speed that the project was able to
find them housing, often within a couple of weeks
of referral. Only one of the eight women
interviewed in 2016 described some problems with
this process – where there had been some delays
and problems with the flat – although these were
overcome in the end. Most of the people
interviewed in 2017 had been housed for some time
(with some having planned moves with the service),
however one interviewee had been waiting for
rehousing for some months, she was staying with
family but was really looking forward to getting her
own home. She thought that the project should
usefully provide supported accommodation to
women whilst they were waiting for their
independent property.
Impact and meaning of successful
rehousing
Staff at Threshold Housing First highlighted the
importance of housing:
The thing is, when they got their accommodation, they realise they can achieve something … they’ve always wanted to change things in their life, but they’ve not been given that opportunity, because they’ve all exhausted services and resources … (Staff member)
Customers explained that getting a property was a
huge weight off their shoulders, that really did
54 Padgett, D. K. (2007). There's no place like (a) home: Ontological security among persons with serious mental
provide an opportunity for them to start building a
new life.
Just hearing those words that I’ve got a property on Monday, it has taken a big weight off my shoulders, it’s like wow, it’s a Godsend. She has been working with me for two weeks and she has just been so amazing, she’s been my angel basically, I want to cry when she phoned me to let me know, I couldn’t believe how quick she did it for me…when they phoned me this morning, I was over the moon – even though the sun was out I wanted the moon out to – to jump over!
What would you say is the most useful thing so far? Getting me a property, because I thought how am I going to get myself sorted like without having somewhere to live, you know … it drives you on the beer because you’ve got nowhere, do you know, so and I am absolutely grateful that they have got me a property. First step isn’t it?
I’m more settled … I’ve been having a lot of problems going on so it’s like a massive weight off of my shoulders knowing that I am staying put.
(Service users)
The importance of a home in creating a sense of
security and safety, sometimes called a sense of
ontological (life) security has been highlighted in
American research among longer term users of
Housing First services. The role of housing as a base
on which to build, providing settled and safe living
was found to be significant in housing sustainment
and movement away from homelessness among
people using Housing First for five years or more54.
Project staff explained that they referred to
people’s new housing as their ‘forever home’, this
term seemed to be realised in some user accounts:
I have never felt that anywhere has been home, but here, with the help they have given me, just doing things, I’ve got it to how I want it, I’ll never move now, that will be me now. … And I feel safe.
(Service user)
illness in the United States. Social science & medicine, 64(9), 1925-1936, p. 1934.
28 | P a g e
I feel like I’m making a nice home, it’s not just a place, it’s a home, and it’s mine, I can call it mine, so that’s a nice feeling as well, to say that I’ve got my own home.
(Service user)
One service user was currently facing a second
housing move as they had dogs and there had been
complaints from other neighbours. This was causing
her considerable distress and felt like this was
making her start all over again as she had felt
settled in the flat.
Health and Well-being
Mental health
Twenty-one women chose to share their own
assessment of their mental health with Threshold
Housing First. Of this group, 14 (two-thirds)
described their mental health as good, a small
number described it as ‘good’ (three women) and
another small group of four women as bad, or very
bad.
Unfortunately, there was no monitoring data
available on changes to mental health. However,
women described how the support was helping
them to better manage their emotions and difficult
situations that they were often facing, and helping
them reduce their anxiety by dealing with problems
immediately and providing support.
Don’t get aggressive with people, don’t get violent, ring me, sound off to me’ and we talk about it the next day … It’s really helped, really really helped, because I am quite aggressive and I lose my temper real quick … with them I can swear and get it all out, and then say thank you! ... I’d be lost without them.
I phone up [the worker] with a problem. I have no way of sorting this out, but [the worker] says, ‘Calm down, give me 2 minutes, I’ll sort it out’, she phones back and it is sorted and I’m like, ‘Wow’, the big weight has gone off my shoulders, and I’m not stressed anymore for the whole day, otherwise I would be stressing for the whole week until I saw her … It’s made me a happier person, definitely – and it’s hard to make me happy! ... I get stuck in my little depression bouts, and obviously if I can’t get out of them depressions then I’m going to stay like that, but [the worker] helps me out of it, she
drags me out… go for a coffee, that gets me out of the house, it gets me meeing people and seeing the world, better than my own four walls.
(Service users)
Women described variable contact and experiences
with mental health services. Whilst obviously
playing a crucial role in some of their lives, the
women were more likely to speak about how
Threshold Housing First was supporting their mental
health more generally – in terms of helping them to
move on with their lives and look forward to the
future.
They have just helped with everything, absolutely everything, they have got my confidence back up … cos I’ve felt for the past few years, with my ex-partner, I’ve been like in a little shell and I’ve not been able to get out of it, but seeing them, talking to them and making plans with them, it has kind of opened me up a little bit … It sounds crazy like … she has done loads, absolutely loads.
(Service user)
For one woman, the service appeared to represent
the last option for them, and one that had really
transformed their mental health. This user was
interviewed twice and she explained that there she
had ‘gone downhill’ a few times, turning her phone
off, but that the Housing First worker always
managed to re-engage her, get her out and about
and back on track.
I know 100% that I would have topped myself – and I would have done it properly this time, there were no options for me, there was no avenues to go, there was nothing, I didn’t have a clue what I was doing, the staff at [supported accommodation] were not doing anything to help, I was asking them … I had nothing, there was nothing I could do … but now I’ve got the world now! I feel so much better, taking care of my hair and my makeup – ask them what I was like when they first met me … I was just slumming, really bad, I was so depressed. … A different outlook on life now, completely .
(Service user)
Threshold Housing First staff believed that there had
been some definite change in women’s mental and
emotional health in the main because the service
could offer an intensive service – this meant that
29 | P a g e
staff could assist people quickly to decrease anxiety,
stress and worry, and also spend the time needed to
reassure clients and undertake health enhancing
activities.
It is the time that we can give these ladies … Instead of that once a week somebody is coming around, they can ring me and say, ‘I’m not feeling great, can you come around tomorrow?’ I can spend all morning with them, do some baking, whatever it is that they want to do, for their mental health. I’m taking women to the gym as well and getting monthly passes for the gym to enable them to go on their own. That all helps their mental health.
(Staff member)
Project staff could also make direct referrals into
one local mental health access team, and were
seeking to replicate this in the other two local
authority areas to ensure speedy referrals could be
made where needed. The project was also hoping to
also facilitate access to counselling services in the
near future, something that service users had
highlighted as needed.
Whilst agencies did not comment on mental health
impacts in detail, a number did consider that the
Threshold Housing First offered a potentially
transformative service to women. The time and
commitment to the women using the service, and
the client led ethos, meant that there was a real
opportunity to empower women to regain control
of their lives and future in a positive way.
A massive difference, an absolutely massive difference … the women that they work with, the investment that they can give is what they really need, it’s the empowerment, it’s the increase in their self worth … they can advocate for them, it is person centred. IF they had the stock of houses there, there wouldn’t be a service that matched up to it, it’s just absolutely outstanding, it just rises above anything else that I’ve heard of or worked with.
(Agency representative)
I think it is having a massive impact … It gives somebody a great deal of independence and I’m guessing that that person would feel quite valued as well, you know, here is a property, we are going to help you, and eventually achieve a level of independence where you no longer need us, that is
quite empowering for a person who has perhaps never had stable accommodation before.
(Agency representative)
Addiction
Nine women had received support in relation to
drug use and eight with alcohol use from Threshold
Housing First. Threshold Housing First staff felt that
some clients had achieved reductions in substance
misuse that had not been captured by the
monitoring to date. Others were still reportedly
struggling with substance misuse issues and not
engaging very well with services. Staff continued to
encourage women to engage with specialist service
within the harm reduction approach of Housing
First. One agency representative commented that
support with substance misuse had been helpful for
one of their clients.
Three of the service users interviewed said that they
had given up alcohol since being with the service,
when previously they were heavy drinkers. A fourth
service user interviewed felt that the support of the
project had enabled them to reduce their alcohol
intake.
I feel better in myself as well you know, like I’ve cut down on the beer, they have changed my life to be honest, you know, getting out of [area] and keeping out of trouble …
(Service user)
Physical health
Twenty-one of the women opted to share their
views on their physical health with the service.
Twelve described their health as ‘fair’ and eight as
‘good’. One reported that their physical health was
‘very bad’.
Eight of the women who had moved into settled
housing in the private or social rented sectors were
registered with a GP, although only five reported
they were registered with a dentist. Data were
incomplete with respect to other women using the
service, although a further 12 reported being
30 | P a g e
registered with a GP and a further three with a
dentist.
Use of A&E was still occurring while using Threshold
Housing First, with six women reporting they had
done so. This may reflect the underlying health
status of the women, which both Threshold’s
anonymised administrative data and the evidence
collected by the research team indicates could
sometimes be poor.
The women were asked about their levels of
physical activity, their diets and smoking. Most
smoked and had not yet given it up, while only a
few reported they were eating healthily. However,
14 women did report themselves to be ‘physically
active’.
Women did not talk about assistance with physical
health to a great degree in the interviews, with the
exception of staff always being there to help
arrange, and often accompany them, to the doctors
and other medical appointments, and how this was
much appreciated.
Social Integration
Education, training and employment
Engagement with education, training and
employment was limited among the women using
Threshold Housing First. Existing research into the
engagement of homeless people with these kinds of
activities has stressed the importance of settled
housing in providing a base from which to
undertake education, training and work seeking
activity55. Employers also usually expect someone to
have a recognisable address before they will offer a
job. The criminal records and the support and
treatment needs of the women were also significant
potential barriers to engaging in formal economic
activity. Some data indicate that former women
prisoners may face even more barriers to work than
55 Pleace, N. and Bretherton, J. (2016) Crisis Skylight: Final Report of the University of York Evaluation. London: Crisis.
male former offenders, ranging from educational
disadvantage through to harsh popular and cultural
attitudes towards women offenders56.
Whilst there was very little concrete progress with
formal ETE, a number of women described a
positive outlook on the future, and some identified
very specific ambitions in their lives often related to
training for a particular occupation. It was notable
that a number described how they wanted to train
in a particular area, rather than simply saying they
wanted to get back into work. The service appeared
to be assisting women to imagine new possibilities
in their lives, a first major step to transforming their
lives.
They have changed my mind-set about everything … things are looking up for me, things are starting to change and look good for me, and I quite like that idea, I like the feel of it. It has proper changed my mind-set about everything and thinking positive.
… way you’re living is better. … Imagined a better place … better place than before …
… you know, I thought I had nothing so I might as well just let go [with alcohol], but now it’s coming back up, and I can look to the future now … get on courses … I want to work … I know I’m going to get to the top, with their help, I know I am …
(Service users)
One women was hoping to get support with getting
a place and funding for a HND explained that the
worker had not yet had the time to look into this.
Crime and anti-social behaviour
The women who used Threshold Housing First all
had been convicted for at least one or two offences.
Thirteen of the 33 women had a history of repeated
convictions, with a small number of this group being
56 Prison Reform Trust (2015) Working it out: Employment for women offenders London. http://www.prisonreformtrust.org.uk/Portals/0/Documents/Employmentbriefing180515.pdf
31 | P a g e
people who could be described as prolific
offenders57.
The nine women who had been housed by
Threshold Housing First and who were still living in
either their private rented sector or social rented
sector housing had collectively committed and been
convicted of 72 offences. One woman had
committed a single offence, another five had
committed between two and five offences and
three had committed more than ten offences, for
which they had been charged and sentenced. Since
they had been housed by Threshold Housing First
they had not been convicted of any offences.
Looking at all the 33 women who had used
Threshold Housing First, who collectively had been
sentenced for a large number of offences58, there
was evidence that offending behaviour continued
among some individuals. As described in Chapter 2,
three women were returned to prison and their
contact with the service ceased, a fourth woman
also spent time in prison, but was an open case, still
receiving support, as at April 2017.
However, offending behaviour was confined to this
small group, only four women were either returned
to prison and/or committed an offence, during the
period for which they were supported by Threshold
Housing First. These data are not conclusive in the
sense that the reasons why offending patterns
change over time are complex and can reduce
simply as people become older. Nevertheless,
women who were in sustained contact with
Threshold Housing First appeared to show a marked
reduction in convictions and offending behaviour,
compared to the patterns of conviction they
reported prior to engaging with the service.
Whilst Threshold Housing First was provided for
women offenders, or those at risk of offending, few
women discussed this aspect of their lives with the
researchers. Although probing questions were
avoided in the interview, it appeared that support
with offending issues were also not central to the
support service. One woman explained that they
57 See Chapter 2.
had asked her if she needed any support with (re)
offending, she had said no, and they had left it at
that. However, one woman explained that the
Threshold service could potentially help her to avoid
custody:
I: What difference has the Threshold service made so far?
Everything, I don’t know, I can’t really explain it, it’s just like is it real?! This time [in prison] if I had known more about Threshold, I think I would have gone straight towards working with them, as well as the women’s centre, cos that is what I should have been doing on Probation, and then if I had known I could have got somewhere housing wise, I probably would have gone in a different direction and stuck to it..
I: Which would have meant …
No prison.
(Service user)
Threshold Housing First staff explained that
monitoring had found a significant reduction in
offending. Staff felt that the stable base and
support, with a high degree of encouragement and
positivity, had made a difference. Effective inter-
agency working with probation and other agencies
also helped to keep customers on track.
A number of agencies reported that the service was
having a direct impact on reducing reoffending. Two
statutory agencies spoke about how the service was
providing ‘protective factors’ via stable
accommodation and getting people out of abusive
situations, and addressing other ‘criminogenic’ risk
factors related to reoffending such as addressing
financial problems, helping with family and other
social networks and providing someone who ‘cares’:
… giving them a life back independently, gives them something to live for and stay out of trouble for … I genuinely believe that it reduces risk, risk of harm, to the women themselves, to the public, to reoffending …
(Agency representative)
58 See Chapter 2.
32 | P a g e
… certainly in terms of the risks for reoffending, having a stable address and this level of support massively helps that, she has now been reduced to medium risk [from high], a large part of that was having this stability and this extra support …
(Agency representative)
The mainstream housing provider interviewed
explained that the support from the project had
enabled anti-social behaviour to be minimised in
their tenancies:
I’m not saying that there are no issues as there always will be issues with clients with complex needs moving into a home … there is a lot of support that goes in, there is a high degree of empathy and sympathy but also from the client a willingness to try and get their lives back on track and maintain the home that they’ve got.
(Agency representative)
Social Networks
Relationships with (ex-)partners
Only two people were recorded as living with a
partner as at April 2017. As Chapter 2 showed, 31 of
the 33 women using the service had experienced
domestic violence in the past, and interviews with
service users and project staff confirmed that many
women were currently escaping domestic violence.
Project staff explained that the service had
supported many women with domestic violence
situations, linking women into specialist domestic
violence services and ensuring that properties were
secure and they had access to personal alarms. In
one area, they could access a sanctuary scheme for
customers. Multi-agency working was key to
progress with links to women’s centres courses and
referrals to MARACs. The project also talked about
healthy relationships. Some customers were now
safe for the first time in a long time. The project also
has links with the police for one housing provider’s
properties so they all have markers so it is a known
domestic violence address. They also have access to
their housing group’s security team who can patrol
outside properties. However, staff admitted that
they were not successful in every case and some
moves had been made for women to escape
partners who were still pursuing them, into both
refuges and on to new tenancies in other areas.
Service users explained that the project (often
working with women’s centres) was succeeding in
helping women address previous domestic abuse in
their lives – this was having a huge impact in terms
of assisting them away from physically and
emotionally harmful situations.
I: What difference has the Housing First service made to you?
It’s just given me a new lease of life, it’s like I can think about taking care of myself, instead of just like having to worry about my ex-partners, I don’t have to go out grafting so I have to pay them so I can stay there, it’s just took all that weight away
(Service user)
Two of the women interviewed explained that the
project had re-located them during their period of
support because of the risk of domestic violence,
one women had to go into a women’s refuge for a
couple of weeks and had now been resettled, the
second woman now felt she had a much safer
house.
This one is better as it has got a front and a back door, the first one only had a front door and he used to stand in front of it, so I had no exit ... so I didn’t feel particularly safe in that place … and I’ve got security doors now as well so I feel a lot safer.
(Service user)
Relationships with children
Only two women were living with children at April
2017, although the majority of service users were
parents, whilst some children were now grown up,
many had experienced their children being taken
into care. Whilst it was not possible for the project
to transform women’s lives in two years to allow the
return of children, a number of service users and
staff reported positive steps forward in terms of
assisting with contact arrangements.
I’ve got children, they are fostered out, I’ve got a letter-box, so [the worker] is going to help me see if there is a way that I can send letters and photos
33 | P a g e
and things like that to it, so we are looking into that as well.
(Service user)
One women, interviewed twice for the research,
had already had children adopted but was being
supported to visit her new baby in foster care. The
service user and project staff both thought that this
contact would have broken down if it was not for
the support. As well as attending appointments, the
worker had advocated for her to ensure that the
same contact worker, as changes were causing her
anxiety. The service user explained:
[The Housing First] worker even comes to contact sometimes, because if I’m having a really bad day, I struggle at contact, leaving the baby, like walking away from her, so [the worker] has to come just for the separation bit, which has massively helped me, well it has stopped me picking up my daughter and walking away with her…They interact with social services because they don’t believe a word I say …
(Service user)
Relationships with wider family and
friends
Twenty-two women shared details about their level
of contact with family. The largest single group (12
women) reported seeing family daily or several
times a week, with the next largest group of five
reporting several times a month. Four women
reported seeing family a few or several times a year,
with only one reporting no contact. This group of
women were not necessarily representative of lone
homeless women as a whole, but the contrast with
what would normally be expected among men with
the same experience of homelessness, i.e. very high
rates of social isolation, is quite striking and again
points to the differences that can exist between
women and men who become recurrently or
enduringly homeless59. Again, data were not
complete, but anonymised data shared by
59 Bretherton, J. (2017) Reconsidering gender in homelessness. European Journal of Homelessness, 11, 1, 1-21.
Threshold showed 17 women were recorded as
having support from family and friends.
Some women interviewed explained that their
relationships with family had improved. For
example, one woman said that contact with her
mother had broken down two years ago, but they
had recently re-established contact. This same
woman had been rehoused close to other family
members and she was now able to assist her sister
with childcare. Another woman explained that after
two years support:
I’ve got my family back now as well because they have seen how good I’ve been doing … so that is another good thing that has come out of it all as well. I’m happy about that … really that is through Threshold because they have helped me get back on the straight and narrow.
(Service user)
Few women spoke about friends. A couple of
service users clearly felt that the project was
providing them with a support network through the
workers. One person felt that the workers were like
‘friends’, and another explained,
I don’t have family, well I do but they are all mentally ill and in supported or sectioned or in long term places, so I don’t have that support network, so this kind of gave me my support network … somebody who I could talk to or get on the phone … she just gives me that place to be able to, I don’t know, exert myself and then just calm down.
(Service user)
Relationships with neighbours/
neighbourhood
Seventeen women shared their views on how they
felt about their neighbourhood. Only three women
out of the 17 who shared their opinions reported a
‘fairly strong’ attachment to their neighbourhood
with the remainder reporting they either felt only a
limited attachment or ‘did not know’ if they felt a
34 | P a g e
strong attachment to their neighbourhood. The nine
women who had been housed in the private rented
and social rented sectors by Threshold Housing First
reported that they did not know if they felt a strong
attachment to their neighbourhood. Although they
are incomplete, these data might be seen as
suggesting a low level of social integration among
the women, but it must be remembered that only
some were in settled housing and that some
neighbourhoods can have a low level of social
integration, particularly where an area is
characterised by socioeconomic deprivation, as
some parts of Greater Manchester are60.
It was clear from the accounts of both servicer users
and Housing First staff that many of the women
found it difficult to go out unaccompanied and this
was likely to have limited their ability to connect
with neighbours and the neighbourhood more
generally. As one woman explained, ‘I keep myself
to myself really, it’s the best way to be really … I
don’t like going out anywhere on my own’.
However, this user went on to explain that the
worker was helping her with this and accompanied
her to museums or for walks. Others were being
helped in similar ways. One service user mentioned
that she always had problems with neighbours but
her new ones were quiet and had been helpful to
her.
Summary
Threshold Housing First was delivering some
important outcomes with a group of long-term and
recurrently homeless women, with histories of
offending and with high and complex needs.
Positive housing outcomes and an increase in
residential stability were being achieved for women
whose lives had been characterised by
homelessness and there was evidence of clear
reductions in offending behaviour, particularly
among women who had been rehoused, but also
60 Once housing costs are taken into account 19.4 per cent of households across Greater Manchester are living in poverty, see: Inclusive Growth Analysis Unit (2017) Patterns of Poverty in Greater Manchester’s Neighbourhoods: Analysis of small area poverty estimates
more generally. There were also some positive
impacts reported by women on the impact of the
service on their mental health and well-being.
Whilst impacts in some areas, notably social
integration, were more varied it would not be
realistic to expect any Housing First service to
deliver universally positive outcomes in a very short
period of time. Recovery from the experiences that
may have been important in causing homelessness,
or which arose during homelessness and made
exiting homelessness more difficult is not an
overnight process.
for 2014 -http://hummedia.manchester.ac.uk/institutes/mui/igau/growthmonitor/GM-MSOA-poverty-briefing-note-2017.pdf.
35 | P a g e
Introduction
This chapter estimates the broad cost effectiveness
of Threshold Housing First.
Contrasting Threshold Housing
First and ‘Treatment as Usual’
Drawing on recent analysis on the costs of single
homelessness in England61 it is possible to produce
some broad estimates on the potential cost savings
that can be achieved by Threshold Housing First.
This is simply a process of contrasting the likely
patterns of service use by a homeless woman with
complex needs if she is without Threshold Housing
First, compared to her patterns of service use if she
is using Threshold Housing First.
There are three basic scenarios that can help
understand the broad cost effectiveness of Housing
First:
Threshold Housing First significantly reduces the
service use of a woman who has made very
extensive use of homelessness services and NHS
services and who has had sustained and
recurrent contact with the criminal justice
system, providing a solution to homelessness
which has a much lower cost than her previous
patterns of service use, i.e. a cost saving is
generated by Threshold Housing First.
Threshold Housing First ends the homelessness
of a woman whose patterns of service use are
expensive, but which may not be much more
expensive than using Housing First. Here the
scenario which is explored centres on the
potential cost effectiveness of Threshold
Housing First, i.e. the service might have similar
61 Pleace, N. and Culhane, D.P. (2016) Better than cure? Testing the case for enhancing prevention of single homelessness in England. London: Crisis.
financial costs to existing services, but may end
homelessness more efficiently.
A woman is experiencing sustained or repeated
homelessness while she has only limited contact
with services, for example a woman with
complex needs has spent significant time living
rough. In this scenario, the costs of providing
her with Threshold Housing First will mean
there is an initial spike in spending, because she
is using the service and the service is connecting
her to health, welfare, social care, drug and
alcohol and other services which she requires,
but has not been accessing. In this scenario,
financial efficiency may be increased over the
medium to long-term because, if her
homelessness persists, the costs of ending her
homelessness are likely to escalate.
These three estimates are of course predicated on
the assumption that Threshold Housing First will be
effective. There will be situations, as this report has
described, where engagement with the service will
not occur, or where it is not sustained, and in which
resources have been used without there being a
clear, positive outcome. Equally, however, a service
like Threshold Housing First may produce some
benefits which have financial implications, even in
those instances where housing is not necessarily
secured and sustained, i.e. relative stability while
supported by Threshold Housing First may produce
short and medium-term reductions in some service
use.
5. Estimates of Cost Effectiveness
36 | P a g e
Estimating the Cost
Effectiveness of Threshold
Housing First
Figure 5.1 shows patterns of service use at
assessment reported by the women using Threshold
Housing First. Women’s centres received quite high
usage, as did drug/alcohol services and GP services.
Use of A&E, direct access (night shelters), day
centres and psychiatric nurse and mental health
services was less common. As described in Chapter
2, contacts with the criminal justice system at
assessment were widespread and in some cases,
frequent.
Figure 5.1 Self-reported patterns of service use at assessment (number of women)
Source: Anonymised data collected by Threshold.
Exact data on how these patterns of service use had
changed with contact with Housing First were not
62 See Chapter 4.
recorded by the administrative data collected by
Threshold. However, there was a clear picture from
the fieldwork that when women had engaged
successfully with Threshold Housing First, housing
stability and support from the Housing First workers
had reduced overall service use. One area that was
recorded, changes in offending over time, showed a
marked reduction once women were using
Threshold Housing First62.
A high cost, high saving scenario
The approximate cost of Threshold Housing First for
the first ten months was £92,000 (between 1
November 2015 and 31 August 2016), i.e. about
£9,200 a month. This would mean an approximate
total of £766 per person, per month, assuming 12
women were being supported, which would equate
to £9,192 per woman using the service per year and
an annual budget of some £110,000. These costs
include only the support element of the Housing
First service, housing costs are handled through the
benefit system (and/or any income the women
using the service may earn).
For the purposes of this scenario, it will be assumed
that one woman would have the following pattern
of service contact over the course of one year:
Two weeks living rough, visiting a day centre
every day.
One month hidden homelessness, visiting a day
centre three times a week.
Three months in a homeless hostel offering low
intensity support.
Six months in temporary supported housing
offering more intensive support.
Ten visits to A&E because she is not registered
with a doctor.
An emergency admission to hospital, including
an ambulance.
Arrested and charged three times for minor
offences.
Arrested and charged, serving one month’s
imprisonment.
0 5 10 15 20 25 30
Direct access
Daycentre
A&E
GP
Mental health services
Psychiatric nurse
Drug/alcohol service
Social Worker
Supported housing
Women's Centre
Daily/Several times a week Weekly
Several times a month Less
37 | P a g e
Spends two weeks in a residential mental health
service.
Sees a community mental health service once a
week for three months.
Sees a drug and alcohol worker twice a week for
two months.
The approximate costs of this pattern of service use,
exclusive of accommodation costs for the hostels,
would be in the region of63:
£208 for day centre use.
£1,152 for the support provided by a homeless
hostel offering low intensity support for three
months.
£6,006 for the support provided by medium
intensity supported housing for six months.
£1,989 for 10 A&E visits.
£3,636 for a hospital admission, being brought
in by ambulance.
£2.157 for being arrested and detained three
times.
£2,786 for being arrested and imprisoned for
one month.
£7,168 for staying in a residential mental health
service for one month.
£1,950 for use of community mental health
services.
£1,116 for use of drug and alcohol worker
services
Approximately £28,168 in total support costs.
There is an element of accommodation cost for the
hostel stays, which are not included here, although
rents for hostels and supported housing which is
provided on a congregate or communal basis may
be higher. As institutional costs, hospital stays and
imprisonment are presented as a total.
63 Estimates are based on data collected for the Pleace, N. and Culhane, D.P. (2016) op. cit. which covered a few local authority areas, none of which were in Greater Manchester. Costs in Manchester may be higher or lower. See Pleace, N. and Culhane, D. (2016) for sources. Data on prison costs (female open prison) are based on Ministry of Justice Figures from Costs per place and costs per prisoner by individual prison: National Offender
Based on the patterns indicated by the research
presented above, it is realistic to envisage a
different scenario if the woman in this scenario
were successfully using Threshold Housing First.
There would be the cost of the service itself, around
£9,192 in support costs per year, but assuming the
service ensured she was stably housed and in
contact with the right services, subject to her own
choices about the support she needed, other costs
might be much lower. Assuming there was zero
offending, a not unrealistic scenario given the
findings shown in Chapter 4, criminal justice costs
would be zero.
A further assumption that her mental health needs
would be supported might mean there was no need
for admission to residential mental health services.
However, as her drug and alcohol and mental health
issues would remain, contact with community
mental health services and with drug/alcohol
services might need to be retained at similar levels,
leaving those costs the same. Equally, while she
should be supported to register and attend a GP,
her health needs would remain, so the A&E costs,
ambulance and hospital admission costs would not
occur, but she would attend the GP multiple times
over the course of a year (we can assume say 10
consultations at around £650 in total). The GP might
arrange access to drug/alcohol and mental health
services more quickly and on a more sustained
basis, which can be allowed for by doubling her use
of these services.
Her costs, in terms of service use, would therefore
drop to approximately £15,974, some £12,196 less
than the scenario where she is not using Threshold
Housing First. Again, this is net of accommodation
and housing costs, the figures are just in relation to
spending on services, in summary64:
Management Service Annual Report and Accounts 2015-16 Management Information Addendum.
64 See Pleace, N. and Culhane, D.P. (2016) op. cit. for sources for these estimates. This study on costs covered a few local authority areas, none of which were in Greater Manchester. Costs in Manchester may be higher or lower.
38 | P a g e
£9,192 on Threshold Housing First support.
£650 on GP appointments.
£3,900 for use of community mental health
services.
£2,232 for use of drug and alcohol worker
services.
£15,974 in total spending, a saving of £12,196.
It can be seen that achieving this kind of result even
ten times produces what start to become quite
significant savings, meaning that a service like
Threshold Housing First starts not only to pay for
itself, but actually reduces total expenditure on
homeless women with high and complex needs. Of
course, the picture is likely to be somewhat more
complex than this, because we know that the costs
of single homelessness are not constant65, so this
chapter will briefly move on to consider two other
illustrative scenarios.
There are potentially higher costs than these for
some women experiencing recurrent and sustained
homelessness. These would arise, for example, if
she had spent more time in NHS residential mental
health services, served a longer prison sentence or
where she had been resident in supported housing
offering high intensity support, which would have a
higher weekly cost. Finally, of course, if her
residence in supported housing had been more
sustained, i.e. she had been resident in hostels or
temporary supported housing for the entire year,
the savings would also be greater.
A medium cost scenario
The financial case for a service like Threshold
Housing First may not always rest on generating
large savings, it will also sometimes be a matter of
greater efficiency being delivered for the same level
of spending. This has been a crucial argument in
supporting the development of Housing First and
65 Pleace, N. and Culhane, D.P. (2016) op. cit.
66 Culhane, DP (2008). The costs of homelessness: a perspective from the United States. The European Journal of Homelessness, 2, 1, 97-114.
other housing-led services in the United States. In
the USA, the use of Housing First has been
encouraged not because the service necessarily
saves money - in fact costs can be broadly similar to
other homelessness services - but because Housing
First ends recurrent and long-term homelessness
among people with high support needs more
efficiently than other services, i.e. better outcomes
are achieved for a similar level of spending66.
For the purposes of this scenario, it will be assumed
that one woman would have the following pattern
of service contact over the course of one year:
Two months living rough, visiting a day centre
every day.
Two months of hidden homelessness, visiting a
day centre five days a week.
Eight months in a homeless hostel offering
medium intensity support.
Eight visits to a GP she is registered with.
Arrested and charged twice for minor offences.
Sees a community mental health service once a
week for six months.
Sees a drug and alcohol worker once a week for
six months.
In this scenario, the woman is in a more stable
situation, she has been in medium intensity
supported housing for a longer period and is
registered with a GP, who has facilitated access to
drug/alcohol and mental health services for a more
sustained period. She has been arrested, but has
not been imprisoned, nor have her mental health
problems reached crisis point and required an
admission into an NHS residential psychiatric
service.
The approximate costs of this pattern of service
use67, exclusive of accommodation costs for the
hostel, would be in the region of:
67 Estimates are based on data collected for the Pleace, N. and Culhane, D.P. (2016) op. cit. which covered a few local authority areas, none of which were in Greater Manchester. Costs in Manchester may be higher or lower. See Pleace, N. and Culhane, D. (2016) for sources.
39 | P a g e
£832 for day centre use.
£8,085 for the support provided by medium
intensity supported housing for six months.
£520 for visiting a GP eight times.
£1,438 for being arrested and detained twice.
£3,900 for use of community mental health
services.
£3,244 for use of drug and alcohol worker
services.
Approximately £17,999 in total support costs.
Here, an alternative scenario in which she is being
supported by Threshold Housing First looks similar
in terms of cost. Her treatment needs will still be
present, so use of the GP and access to community
mental health and drug/alcohol services may be
very similar. The costs that may not occur, based on
what this research has shown, are those associated
with being arrested and, of course, the daycentre
and supported housing costs that will not arise
because she has been housed by Threshold Housing
First.
£9,192 on Threshold Housing First support.
£520 for visiting a GP eight times.
£3,900 for use of community mental health
services.
£3,244 for use of drug and alcohol worker
services.
Approximately £16,836 in total support costs, a
reduction of £1,163.
In this scenario, Threshold Housing First costs about
the same as the pattern of service use that would
have occurred if the woman had not had access to
the service. The difference of course, lies not so
much in the costs, but in the fact that she has
sustained an exit from homelessness, with all the
attendant risks and costs associated with sustained
and recurrent homelessness being removed. In this
kind of scenario, Threshold Housing First is still
paying for itself and generating a small saving, but,
crucially, similar levels of spending are achieving
68 Pleace, N. and Culhane, D.P. (2016) op. cit.
more, because an exit from homelessness has been
achieved.
A Scenario where Threshold Housing
First may increase short-term costs
The exception to a service like Threshold Housing
First either offering a potentially better outcome at
a similar cost, or a significant financial saving and a
better outcome is where recurrent or sustained
homelessness associated with high support needs is
not associated with significant service use. This
would be a situation in which a woman with
complex needs was living rough, squatting or in
some other arrangement, such as living in a tent or
a car, and was making little or no use of support
services. She might access food and low level
support at a daycentre, but would not stay in
emergency accommodation, she has no contact
with the NHS and, if she is committing any crime,
she does not get caught doing it.
In this instance, costs go from what is probably a
very low level to a considerably higher level. Part of
this is because instead of receiving little or no
support, she is instead receiving Threshold Housing
First, but the main costs may be because Threshold
Housing First starts to connect her to the benefits
system, NHS and other services. This is a possible
scenario, but in reality costs are unlikely to be near-
zero on a sustained basis if her homelessness is
sustained. The available evidence shows that when
someone remains living rough for protracted
periods, they will, sooner or later, tend to have
contact with emergency health, mental health and
criminal justice services68. Equally, as homelessness
persists, the costs of extricating someone from it
tend to increase.
The referral points for many of the women using
Threshold Housing First are also important to note
here, as many had been in prison. The role of
Threshold Housing First in providing the residential
stability and support that can reduce recidivism is
clear, the service was associated with marked
40 | P a g e
reductions in offending. The potential for cost
saving and for better use of spending on
homelessness associated with a history of offending
also extends to the reductions in contacts with the
criminal justice system.
Potential Savings in Local
Authority Spending
The potential savings for local authorities and across
the Greater Manchester Combined Authority,
centre on two main areas of expenditure:
Provision of temporary supported housing
Administration of the statutory homelessness
system, specifically:
o Homelessness prevention and relief o The Main Duty
Again, the financial benefits of Threshold Housing
First can be shown by using an illustrative example.
Focusing just on local authority spending, if we
assume a woman with complex needs visits a
Housing Options Team three times, receives two
preventative interventions which are unsuccessful
and is accepted as statutorily homeless and owed
the Main Duty on her third visit, being placed in
temporary supported housing for six months before
she is rehoused, the potential direct cost might look
broadly as follows69:
Two unsuccessful preventative interventions
costing £800 each.
Found statutorily homeless and owed the Main
Duty, costing £800.
Temporarily accommodated in a B&B will
assessment is carried out, £70 a night for two
weeks, £980.
Placed in supported housing on a temporary
basis for six months, at £230 a week in support
costs, £5,980 (the benefits system will pay her
rent).
Total costs of £9,360.
69 For assumptions/sources see Pleace, N. (2015) At What Cost? An estimation of the financial costs of single homelessness in the UK. London: Crisis.
This is only an illustrative example, but the local
authority has spent the equivalent of the cost of a
year of Threshold Housing First, while only getting
the woman to the point where she housed. This
woman has complex needs, she will require
something like Threshold Housing First in order to
sustain her tenancy, i.e. there will be more spending
needed to sustain an exit from homelessness. By
contrast, a referral to Threshold Housing First
would, if all goes well, remove these costs. The
potential role of Threshold Housing First at strategic
level in the Greater Manchester Combined
Authority, in the context of the 2017 Homelessness
Reduction Act, is discussed in the next chapter.
Measuring Costs
Ideally, systems should be in place to measure costs
more effectively. One way to do this is to compare
two groups of very similar women over time, with
one group using conventional services to end their
homelessness and the other using Threshold
Housing First. This kind of study can be extremely
useful, because it can clearly evidence the kinds of
cost benefits that a service like Threshold Housing
First may generate, but, in practice, this kind of
work is difficult to get funded in the UK.
Another approach is to merge or collect data on
historical patterns of service use. Understanding
what women’s patterns of service use were prior to
engaging with Threshold Housing First and then
comparing changes in service use over time, can
give a good indication of where financial benefits
may be achieved. The longer the period that can be
analysed, the better in terms of understanding what
the cost benefits of a service like Threshold Housing
First are.
In the meantime, it is possible to estimate and to
model, as has been attempted in this chapter. It can
be seen there is the potential for Threshold Housing
First and similar services to deliver better results for
similar expenditure and, in some cases, to
41 | P a g e
potentially reduce overall spending. However, there
is a real need to collect hard data that can show
how patterns of service use may change as a result
of engaging with Threshold Housing First and –
ideally – to run a trial that will compare Threshold
Housing First with the other service options for
women with a history of homelessness and high and
complex needs.
Impact of Project on Agencies
A number of agencies commented that the
Threshold Housing First service had a positive
impact on their service, in terms of supporting their
work, either via relieving the pressure on them
where they did not have enough time to support
their clients, or by supporting their agencies aims by
helping women into a more stable situation so that
their work is likely to be more effective. A refuge
provider also pointed out that people stay in refuges
longer because they cannot access appropriate
properties. Whilst it was not possible to cost these
impacts, these would represent cost savings.
The service that I work in, it relieves us as if they are attending an appointment with the support worker, I don’t need to necessarily see … it helps us to have someone there giving extra support …
(Agency representative)
We are trying to do some in-depth work around thinking skills, problem solving, well when you’ve got someone coming in who is street homeless, it’s very hard to do that kind of work, when their acute needs are so high, and our service there is very little that we can do about that, so unless you get that sort of stable base, that is the foundation that we need to work on, I don’t see how we can do any meaningful work really, you know, goal setting, goal achieving, if someone doesn’t know where they are going to sleep tonight, how can we talk about problem solving or look at reducing reoffending … massively, massively positive …
(Agency representative)
Summary
At present it is not possible to provide exact data on
the cost effectiveness of Threshold Housing First.
Modelling the potential costs of the service
compared to other possible patterns of service use
indicates that there is clear scope for Threshold
Housing First to potentially deliver better outcomes
at a similar or lower cost than existing services.
42 | P a g e
Introduction
This final chapter critically assesses the
achievements of Threshold Housing First and then
considers the case for further development of
Housing First services with a specific focus on
homeless women.
The Achievements of Threshold
Housing First
Threshold Housing First represents a significant
innovation and a significant achievement. Much has
been accomplished by a service that has highlighted
an extremely damaging form of homelessness
among women with very high and complex needs,
recognised and supported their strengths and
provided them with a sustainable exit from
homelessness. Among the women who agreed to be
interviewed, the crucial role that Threshold Housing
First had played in facilitating an exit from
homelessness and helping them with their other
needs was emphasised again and again. For some of
the women, engaging with Threshold Housing First
had been life changing. These findings are
reinforced by the findings from discussions with
partner agencies about the contribution of
Threshold Housing First and in the opinions of the
staff about the quality of the service they were
providing.
No service is perfect and there are issues with
attrition and challenges in securing the right kind of
housing with sufficient speed, but these issues
should not distract from the very considerable
achievements of Threshold in developing and
piloting this Housing First service.
70 Bretherton, J. (2017) op. cit.
Threshold has actively promoted the Housing First
service and engaged proactively with partner
agencies. As is described below, collaboration with a
philanthropic partner has now assured the future of
the service for the next three years and created the
potential for Threshold Housing First to undertake a
key role in the Greater Manchester Combined
Authority response to homelessness at a strategic
level.
The Case for Dedicated Housing
First Services for Women
This is the first examination, so far as the authors
are aware, of a Housing First service focused
specifically on women. While Housing First services
have been working with women since they first
became operational in New York in the early 1990s,
their focus has tended to be more towards men,
because these services were targeted on men who
were long-term and recurrently homeless and living
rough or in emergency accommodation.
Understanding of the possible extent of
homelessness among women with complex needs is
starting to change, as new evidence reveals the
extent to which this group relies on friends, relatives
and acquaintances to keep some sort of roof over
their head starts to become apparent, and the
hidden nature of women’s homelessness begins to
be properly understood70.
That the women using Threshold Housing First have
distinct, gender-specific, support needs is self-
evident. The main evidence for this can be
summarised as follows:
6. The Future for Threshold Housing
First
43 | P a g e
The extent of experience of gender-based or
domestic violence and abuse, both as a factor in
homelessness causation, but also as a near-
universal life experience among the women
using Threshold Housing First. The successful
management of former and ongoing abusive
relationships, ensuring women are safe, secure
and are getting the support they need, is a core
function of the service, because without
ensuring the safety and wellbeing of the women
using it, the Threshold Housing First service
cannot provide a sustainable end to their
homelessness.
The consequences of fractured relationships
also created specific needs. These women had
very often lost contact with their children, in
some instances having them removed due to
Child Protection concerns, which again could
often mean they had specific support needs.
Threshold Housing First was targeted on a
specific group of women in the sense that
alongside high and complex support needs and
often sustained experience of homelessness,
many were ex-offenders. Whilst their
engagement with Threshold Housing First often
showed their strength and capacity, the support
needs of these women were very high. There
are hints from other research that women with
experience of sustained and recurrent
homelessness may have typically higher needs
than men. Whilst it is not possible to confirm
this, the women using Threshold Housing First
had typically higher needs than the largely male
groups using the English Housing First pilots71.
The initial pilot of the Camden Housing First
service, which has since expanded also found
some evidence that women had typically higher
needs than men72.
71 Bretherton, J. and Pleace, N. (2015) op. cit.
72 Pleace, N. and Bretherton, J. (2013) op. cit.
73 Bertakis K.D., Azari, R., Helms, L.J., Callahan, E.J. and Robbins J.A (2000) Gender differences in the utilization of health care services. Journal of Family Practice, 49, 2.
74 Garcia-Moreno, C., Jansen, H.A., Ellsberg, M., Heise, L. and Watts, C.H. (2006) Prevalence of intimate partner violence: findings from the WHO multi-country study on
These kinds of support needs and experiences are,
of course, not limited to women. Men will
sometimes experience domestic violence and abuse
and there can be high support needs associated
with what is a highly traumatic experience. Men will
also experience fractured relationships with their
children and, as with women, there are male
individuals who represent the highest extremes of
complex need found among homeless people.
It is arguable to say that experiences will not
necessarily be processed and coped with in the
same way by each gender, i.e. women may need
other women who understand their needs, within a
broader cultural context in which men may also feel
more comfortable receiving support from other
men for the same reason. It is clear that men and
women use health services in different ways, for
example73, and that may suggest they want and
need different things from homelessness services.
Yet the real differences and the case for dedicated
Housing First services for women may ultimately
rest on the differences in the frequency and extent
of these experiences. The reality is that men
experience domestic violence and abuse at a
fraction of the rate experienced by women, so that
while domestic violence is not a wholly female
experience, it is, in the UK and globally, an
overwhelmingly female experience74. Equally, long-
term and recurrent male homelessness is often
broadly characterised by an absence of relationships
for protracted periods75, whereas almost all the
women using Threshold Housing First had children
and very recent ex-partners. Whether women who
are long-term and recurrently homeless tend to
have even higher support needs than men is not yet
possible to judge, but that possibility also exists.
women's health and domestic violence. The Lancet, 368, 9543, 1260-1269.
75 Busch-Geertsema, V.; Edgar, W.; O’Sullivan, E. and Pleace, N. (2010) Homelessness and Homeless Policies in Europe: Lessons from Research, Brussels: Directorate-General for Employment, Social Affairs and Equal Opportunities.
44 | P a g e
There is no evidence to suggest that there is any
requirement to modify the core principles of the
Housing First in order to provide a service focused
on women with high and complex needs. In terms
of the core philosophy of Housing First, Threshold
Housing First is a high fidelity model. However,
some modification to the detail of operation, for
example in relation to handling the widespread
experience of domestic violence and abuse among
women using the service, is likely to be required.
A Strategic Role for Threshold
Housing First in the Greater
Manchester Combined
Authority
The Greater Manchester Combined Authority
(GMCA)76 elected its first Mayor in 2017. One aspect
of the Mayor’s campaign was a focus on the
growing levels of people living rough across Greater
Manchester. The Greater Manchester Mayoral
Homelessness Fund was established in 2017 and is
designed to assist local organisations to tackle
homelessness in all of its forms across the
Manchester region. Greater Manchester now has a
strategic goal to end rough sleeping by 2020, or
earlier, if possible. The GM Mayoral Homelessness
Fund will eventually take the form of a crowdfunded
Community Foundation, working as an independent
charity which will disseminate funds to local
organisations through a grant application process.
At strategic level, GMCA is functioning as one of the
‘early adopter’ (pilot) regions which are testing the
implementation of the 2017 Homelessness
Reduction Act (HRA). The HRA, drawing on recent
Welsh legislative reforms, brings a new focus and
intensity on homelessness prevention across the
entire statutory system, representing the most
radical change in English homelessness law since the
original 1977 legislation was introduced.
76 The Greater Manchester Combined Authority includes ten local authorities: Bolton, Bury, Manchester, Oldham, Rochdale, Salford, Stockport, Tameside, Trafford and Wigan, see: https://www.greatermanchester-ca.gov.uk.
The HRA changes the emphasis in the homelessness
legislation from a ‘reactive’ approach, i.e. acting
after homelessness has occurred, to a preventative
approach, i.e. stopping homelessness from
occurring where possible. Since 2003, England has
been moving towards an increasingly preventative
focus in response to homelessness, but the process
has now been taken further and faster by recent
Welsh legal reforms, which appear to have reduced
overall levels of homelessness. Local authorities are
required to intervene at earlier stages, up to and
beyond 56 days before homelessness will occur, to
prevent homelessness and to take reasonable steps
to ensure people who become homeless can secure
accommodation. The goal is that support should be
in place before anyone reaches a point where they
have nowhere safe to stay.
The HRA places new responsibilities on public
services to deliver a coordinated response to
homelessness. The NHS, for example, should notify
local authorities if it is working with someone who
may be facing homelessness. Greater coordination
across public services is a key goal for GMCA and
work is underway by the Greater Manchester Health
and Social Care Strategic Partnership Board to
develop a GMCA wide, coordinated, response to
homelessness at the time of writing77. A recent
planning document notes:
Our objective will be to drive a shift towards prevention and earlier intervention so that fewer individuals and families face the risk or reality of homelessness; and those that do face crises and more swiftly supported into recovery and stability. This will mean both a focus on more effective proactive investment in prevention and driving down reactive costs. The system will be designed to tackle underlying issues as early as possible and local services will be integrated to provide people with an individually tailored pathway approach to provide the whole package of support they need to get sustainably back on their feet and improve
77 See: http://www.gmhsc.org.uk/assets/11-Health-and-Homelessness-FINAL-1.pdf.
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their life chances, not just to get a roof over their heads.78
In practical terms, as will be the case in other
combined authorities such as Liverpool City Region
and Sheffield City Region, alongside individual local
authorities with responsibility for housing, this
means the development of a GMCA wide strategic
approach which will have the following elements:
1. Universal Prevention, designed to provide advice and assistance to anyone potentially threatened with homelessness.
2. Targeted Prevention, focused on people at greater risk of homelessness.
3. Crisis Prevention and Relief, which is designed to very rapidly end homelessness when it has occurred.
4. Recovery, which covers accommodation and support services targeted on enabling people to exit from homelessness as rapidly as possible.
5. Move-On Support, which provides longer term support to any homeless person requiring it to sustain independent living.
There are a range of service models designed to
support this broad approach including housing
advice services, rent deposit and bond schemes,
debt and money advice services, sanctuary schemes
for those at risk of domestic violence and an array of
floating support and accommodation-based
services. All of this service provision is designed to
work in a coordinated way with health and social
services, with local authority and voluntary and
charitable sector services working towards a
common goal of maximising homelessness
prevention.
Threshold Housing First has moved from a position
of working as a pilot service which Threshold was
supporting with its own resources to one in which
the core service will be supported by a philanthropic
78 Greater Manchester Health and Social Care Strategic Partnership Board (31 March 2017) report on Health and Homelessness, see http://www.gmhsc.org.uk/assets/11-Health-and-Homelessness-FINAL-1.pdf
79 See Chapter 1.
source for the next three years. The goal for
Threshold Housing First is to develop working
relationships beyond the three GMCA local
authorities in which it currently works, Tameside,
Stockport and Oldham79 and towards building a
strategic level role with the other authorities across
Greater Manchester as a whole. This will involve
developing contractual arrangements with local
authorities which will allow Threshold Housing First
to begin a process of snowballing together
additional funding, expanding geographical
coverage and the overall size of the service as it
progresses. Service users and agencies involved with
threshold Housing First both wanted to see the
service expand to new areas. One agency
representative also strongly argued for developing a
preventative arm of the service to assist women
with complex needs who were struggling with
tenancies.
There is a clear case for exploring direct support for
Threshold Housing First across GMCA as part of the
overall homelessness and rough sleeping strategy.
The roles for the service can be summarised as
follows:
Removing entrenched rough sleeping among
women with complex needs from GMCA.
Addressing recurrent homelessness among
women with complex needs who are ‘stuck’ in
existing services.
Breaking the association between offending,
contact with the criminal justice system and
sustained and recurrent homelessness among
women.
A recent theoretical exercise has explored the
potential for integrating Housing First into the
nearby combined authority, Liverpool City Region80.
This exercise was not based on the actual
implementation of a Housing First service across
that region, but instead focused on how the
80 Blood, I., Copeman, I., Goldup, M., Pleace, N., Bretherton, J. and Dulson. S. (2017) Housing First Feasibility Study for the Liverpool City Region. London: Crisis.
46 | P a g e
practicalities of implementing Housing First would
work, talking to homeless people and to many of
the agencies that would be involved in
implementing Housing First. This exercise identified
several points of interest:
International evidence shows that where
Housing First has been used successfully in
strategic responses to homelessness, it has been
given a clear role within a wider integrated
homelessness strategy.
A shared database on supported housing use
across Liverpool City Region indicated the
presence of a high cost, high risk group of
homeless people who were effectively stuck in
existing temporary supported housing services,
staying in services for protracted periods or
moving between one service and another in a
‘revolving door’ situation in which their
homelessness was not being resolved.
Particular weaknesses existed around prison
release as it related to homelessness, with
issues around poor coordination and an absence
of services designed specifically to support ex-
offenders facing a high risk of sustained or
recurrent homelessness.
The Liverpool study failed to explore gender issues
in any detail, but has highlighted the potential roles
that Housing First can play within the integrated,
coordinated and preventative homelessness
strategies that will be required under the HRA.
These can be summarised as follows:
1. Universal Prevention, Housing First would not be expected to play a role in these front line services
2. Targeted Prevention, where systems are properly coordinated, women who are identified as having high support needs and as at potential risk of homelessness can be effectively triaged to Threshold Housing First, i.e. the service can be incorporated into the preventative functions of the wider homelessness strategy.
3. Crisis Prevention and Relief, Threshold Housing First has a clear role when homelessness has occurred and a woman has high and complex support needs.
4. Recovery, the Housing First model is designed explicitly to support this element of a homelessness strategy and Threshold Housing First can again be targeted on women with complex needs.
5. Move-On Support, can be provided by Threshold Housing First where a woman requires longer term support for independent living, again focused on those cases when someone has high and complex needs.
The role of Threshold Housing First within wider
homelessness strategy across GMCA centres on
women with high and complex needs. One aspect of
this role is a capacity to end homelessness among
women with these characteristics who are sleeping
rough, which this research demonstrates. Threshold
Housing First can support the specific agenda of the
Mayor in relation to ending rough sleeping across
GMCA by 2020. Within broader homelessness
strategy Threshold Housing First can fulfil three
important roles:
Acting as a preventative service when women at
risk of homelessness have high and complex
needs.
Providing a sustainable exit from homelessness
at a crisis point when a woman with high and
complex needs has just become homeless, i.e. a
‘relief’ function.
Preventing sustained and recurrent
homelessness among women who have become
homeless and who require support to enable
them to make a lasting exit from homelessness.
Summary
Threshold Housing First has delivered some very
positive results. While the service is not perfect,
there is clear evidence that it has provided effective
support that was highly valued by the women using
the service and by partner agencies. The research
indicates that there is a case for exploring variants
of the Housing First model which are specifically
focused on homeless women with complex needs.
This does not require any change to the core
principles of the original Housing First model,
though some operational modifications, for example
around the management of potential domestic
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violence, are necessary. There is a case for
Threshold Housing First to be integrated into the
strategic response to homelessness across GMCA,
where it has the potential to play a preventative
role, deliver relief from homelessness at a crisis
point and provide sustainable exits from
homelessness for women with high and complex
needs.
For more information about our research, please contact:
Centre for Housing Policy
University of York
York YO10 5DD
Telephone: +44 (0)1904 321480
Email: [email protected]
Twitter: @CHPresearch
or visit our website:
https://www.york.ac.uk/chp/
